Healthcare Provider Details

I. General information

NPI: 1093422636
Provider Name (Legal Business Name): JESSICA LANEICE WILSON BHRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LANEICE JEFFERY

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 LAUREL ST
ANCHORAGE AK
99508-5338
US

IV. Provider business mailing address

8444 N 90TH ST STE 100
SCOTTSDALE AZ
85258-4437
US

V. Phone/Fax

Practice location:
  • Phone: 907-782-4750
  • Fax:
Mailing address:
  • Phone: 602-248-8886
  • Fax: 907-729-6353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number236190
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: