Provider Demographics
NPI:1265827729
Name:LUCCA, JESSICA E (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:LUCCA
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:E
Other - Last Name:SWINFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:217-788-3948
Mailing Address - Fax:217-527-3209
Practice Address - Street 1:319 E MADISON ST STE 1F
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-3118
Practice Address - Country:US
Practice Address - Phone:217-788-3948
Practice Address - Fax:217-527-3209
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012661207RC0001X, 363LG0600X, 363LA2100X
IL209012661363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041.375925OtherRN LICENSE
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid