Provider Demographics
NPI:1831594670
Name:WILLEMSE, JESSICA LYNN (NP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WILLEMSE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12209
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-2209
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:909-478-3644
Practice Address - Street 1:34845 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4268
Practice Address - Country:US
Practice Address - Phone:909-500-7971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001558363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily