Basic Information
| Provider Information | |||||||||
| NPI: | 1790867471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIM | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 S MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241535012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404049637 | ||||||||
| FaxNumber: | 5404044146 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 S MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241535012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404049637 | ||||||||
| FaxNumber: | 5404044146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001235693 | VA | N | Nursing Service Providers | Registered Nurse | 363LG0600X | AG0715012 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | AG0715012 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.