Provider Demographics
NPI:1770889669
Name:CUNNINGHAM, JESSICA JEAN (RN, LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEAN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:RN, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30286 FOX RUN RD
Mailing Address - Street 2:
Mailing Address - City:STACY
Mailing Address - State:MN
Mailing Address - Zip Code:55079-9653
Mailing Address - Country:US
Mailing Address - Phone:651-269-3362
Mailing Address - Fax:
Practice Address - Street 1:30286 FOX RUN RD
Practice Address - Street 2:
Practice Address - City:STACY
Practice Address - State:MN
Practice Address - Zip Code:55079-9653
Practice Address - Country:US
Practice Address - Phone:651-269-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 199450-0163W00000X
MNL 067912-7164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse