Healthcare Provider Details

I. General information

NPI: 1053111930
Provider Name (Legal Business Name): JALISA MARIE SIMPSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 STANTON CHRISTIANA RD STE 303
NEWARK DE
19713-2135
US

IV. Provider business mailing address

PO BOX 67537
NEWARK NJ
07101-8009
US

V. Phone/Fax

Practice location:
  • Phone: 302-861-8035
  • Fax: 302-600-3589
Mailing address:
  • Phone: 302-400-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF12240720
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: