Basic Information
| Provider Information | |||||||||
| NPI: | 1902278476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 N SECTION ST | ||||||||
| Address2: | PO BOX 10 | ||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122684311 | ||||||||
| FaxNumber: | 8122682652 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 N SECTION ST | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122684311 | ||||||||
| FaxNumber: | 8122682652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2015 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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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 | 363L00000X | 71005765A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.