Basic Information
| Provider Information | |||||||||
| NPI: | 1457639403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOOD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | FAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNM, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 RENFERT WAY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787585444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124253825 | ||||||||
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| Practice Location | |||||||||
| Address1: | 975 RYLAND ST | ||||||||
| Address2: | STE 105 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825640 | ||||||||
| FaxNumber: | 7759825641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2011 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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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 | 367A00000X | CNM0556 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LX0001X | APN001446 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | AP128016 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1457639403 | 05 | NV | MEDICAID | 12428218 | 01 | CAQH | OTHER |