Basic Information
| Provider Information | |||||||||
| NPI: | 1780023523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICSSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MSN- FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3031 NORTHSIDE RD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240192707 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2013 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024170830 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.