Healthcare Provider Details

I. General information

NPI: 1932956679
Provider Name (Legal Business Name): AMANDA NICOLE JESSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 02/11/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 BLUE LAKE DR STE 110
VESTAVIA AL
35243-2372
US

IV. Provider business mailing address

5007 NATALIE WAY
TRUSSVILLE AL
35173-1197
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-1949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-144029
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: