Provider Demographics
NPI:1811272420
Name:GAGNON, JESSICA ANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 THOMAS ST
Mailing Address - Street 2:APT. 4C
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3900
Mailing Address - Country:US
Mailing Address - Phone:518-598-6585
Mailing Address - Fax:
Practice Address - Street 1:16 THOMAS ST
Practice Address - Street 2:APT. 4C
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3900
Practice Address - Country:US
Practice Address - Phone:518-598-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY616268-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse