Provider Demographics
NPI:1295456184
Name:SANFORD, JESSICA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SE DORR DR APT SUITE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:IA
Mailing Address - Zip Code:50327-8564
Mailing Address - Country:US
Mailing Address - Phone:515-554-4787
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5074
Practice Address - Country:US
Practice Address - Phone:855-984-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA170959208D00000X, 363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily