Basic Information
| Provider Information | |||||||||
| NPI: | 1225617731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEATHERWAX | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | HADDON TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081082420 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153165151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2021 | ||||||||
| LastUpdateDate: | 04/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | SP023562 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.