Healthcare Provider Details

I. General information

NPI: 1205451366
Provider Name (Legal Business Name): JESSICA WYCKOFF DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2020
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12497 TAMIAMI TRL S STE 1
NORTH PORT FL
34287-1415
US

IV. Provider business mailing address

12497 TAMIAMI TRL S STE 1
NORTH PORT FL
34287-1415
US

V. Phone/Fax

Practice location:
  • Phone: 941-282-3376
  • Fax: 941-282-3378
Mailing address:
  • Phone: 941-282-3376
  • Fax: 941-282-3378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11007428
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: