Healthcare Provider Details

I. General information

NPI: 1306464599
Provider Name (Legal Business Name): JESSICA MINOR CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 E SOUTH BLVD STE 505
MONTGOMERY AL
36116-2004
US

IV. Provider business mailing address

301 BROWN SPRINGS RD
MONTGOMERY AL
36117-7005
US

V. Phone/Fax

Practice location:
  • Phone: 334-747-5000
  • Fax:
Mailing address:
  • Phone: 334-747-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-157890
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: