Provider Demographics
NPI:1952081119
Name:BACON, JESSICA WILSON (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:WILSON
Last Name:BACON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2856
Mailing Address - Country:US
Mailing Address - Phone:252-413-0720
Mailing Address - Fax:
Practice Address - Street 1:613 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2856
Practice Address - Country:US
Practice Address - Phone:252-413-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily