Basic Information
Provider Information | |||||||||
NPI: | 1003883661 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SNOOK | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 936 | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235010936 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574465955 | ||||||||
FaxNumber: | 7574465196 | ||||||||
Practice Location | |||||||||
Address1: | 825 FAIRFAX AVE | ||||||||
Address2: | 118 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235071914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574465955 | ||||||||
FaxNumber: | 7574465196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 01/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0017138304 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 0001156770 | VA | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | -002 -003 | 01 | VA | TRICARE/CHAMPUS | OTHER | 7003995 | 05 | NC |   | MEDICAID | 03995 | 01 | NC | NC BC/BS | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | 010165393 | 05 | VA |   | MEDICAID | 95827N | 01 |   | SENTARA / OPTIMA | OTHER |