Provider Demographics
NPI:1255704599
Name:BOGGS, JESSICA E (ANP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:BOGGS
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:E
Other - Last Name:BLAHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-C
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1100 E MONTCLAIR ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5076
Practice Address - Country:US
Practice Address - Phone:417-820-8500
Practice Address - Fax:417-820-8532
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015034077363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1255704599Medicaid
MO132680741Medicare PIN