Provider Demographics
NPI:1780023523
Name:ERICSSON, JESSICA S (MSN- FNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:ERICSSON
Suffix:
Gender:F
Credentials:MSN- FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 NORTHSIDE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170830363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily