Healthcare Provider Details

I. General information

NPI: 1932734878
Provider Name (Legal Business Name): JESSICA MAE LIGHT APN, AGNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12230 LIONESS WAY
PARKER CO
80134-5603
US

IV. Provider business mailing address

12230 LIONESS WAY
PARKER CO
80134-5603
US

V. Phone/Fax

Practice location:
  • Phone: 720-644-9355
  • Fax:
Mailing address:
  • Phone: 720-644-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN.0995140-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN.0995140-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: