Basic Information
Provider Information | |||||||||
NPI: | 1013196310 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCELHOSE | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | JEANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FRY | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | JEANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3020 CHILDRENS WAY # MC5008 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921234223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8589665818 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3010 CHILDRENS WAY | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921234223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8589665818 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2007 | ||||||||
LastUpdateDate: | 06/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | AP60037772 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0005X | NP95012326 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
ID | Type | State | Issuer | Description | 8949510 | 01 | WA | LABOR & INDUSTRIES CRIME VICTIMS | OTHER | 00043791-00 | 05 | FL |   | MEDICAID | 9659434 | 05 | WA |   | MEDICAID | 003118865A | 05 | GA |   | MEDICAID |