Healthcare Provider Details

I. General information

NPI: 1528787124
Provider Name (Legal Business Name): JESSIKA MOULTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 43RD ST N
PINELLAS PARK FL
33781-3601
US

IV. Provider business mailing address

2115 CENTRAL AVE
ST PETERSBURG FL
33713-8815
US

V. Phone/Fax

Practice location:
  • Phone: 727-824-8181
  • Fax:
Mailing address:
  • Phone: 727-526-9135
  • Fax: 727-526-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN11020722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: