Basic Information
Provider Information | |||||||||
NPI: | 1376796987 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEBB | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 NW IMAN CEMETERY RD | ||||||||
Address2: |   | ||||||||
City: | STEVENSON | ||||||||
State: | WA | ||||||||
PostalCode: | 986486365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039393029 | ||||||||
FaxNumber: | 5033634607 | ||||||||
Practice Location | |||||||||
Address1: | 25 NW IMAN CEMETERY RD | ||||||||
Address2: |   | ||||||||
City: | STEVENSON | ||||||||
State: | WA | ||||||||
PostalCode: | 986486365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039393029 | ||||||||
FaxNumber: | 5033634607 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2008 | ||||||||
LastUpdateDate: | 01/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP60196762 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201050138NP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 123190 | 05 | OR |   | MEDICAID |