Provider Demographics
NPI:1780274563
Name:EASTMAN, JESSICA ANN (CNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:REESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7115 FORTHUN RD SUITE 105
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425
Mailing Address - Country:US
Mailing Address - Phone:218-454-0090
Mailing Address - Fax:
Practice Address - Street 1:7115 FORTHUN RD #105
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-454-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7955363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health