Basic Information
| Provider Information | |||||||||
| NPI: | 1417929910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIBODEAU | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035856508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038388967 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 MOUNT EUSTIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035613712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034442464 | ||||||||
| FaxNumber: | 6034443441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 0417842305 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 30009281 | 05 | NH | MEDICAID |