Healthcare Provider Details

I. General information

NPI: 1710225982
Provider Name (Legal Business Name): JESSICA WILLOUGHBY LM,CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 DR MLK JR ST N
SAINT PETERSBURG FL
33704
US

IV. Provider business mailing address

1501 20TH AVE N LOWR
SAINT PETERSBURG FL
33704-3909
US

V. Phone/Fax

Practice location:
  • Phone: 727-895-2300
  • Fax: 727-895-2375
Mailing address:
  • Phone: 813-404-7120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW289
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: