Basic Information
| Provider Information | |||||||||
| NPI: | 1982929147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 276 FIELDSTONE DR | ||||||||
| Address2: | |||||||||
| City: | JONESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242631215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765465310 | ||||||||
| FaxNumber: | 2765465469 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 MONARCH ROAD | ||||||||
| Address2: | |||||||||
| City: | ST. CHARLES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242820269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763834428 | ||||||||
| FaxNumber: | 2763834927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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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 | 363LF0000X | 0024168689 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100152500 | 05 | KY | MEDICAID |