Basic Information
| Provider Information | |||||||||
| NPI: | 1285359158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1737 EAGLE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637553244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732580811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733313000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2022 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 2004019083 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 163W00000X | 2004019083 | MO | Y | Nursing Service Providers | Registered Nurse |
No ID Information.