Healthcare Provider Details

I. General information

NPI: 1801358908
Provider Name (Legal Business Name): JESICA GOULD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 36TH AVE
MOLINE IL
61265-7127
US

IV. Provider business mailing address

1236 E RUSHOLME ST STE 300
DAVENPORT IA
52803-2473
US

V. Phone/Fax

Practice location:
  • Phone: 309-743-6700
  • Fax:
Mailing address:
  • Phone: 563-324-2992
  • Fax: 563-324-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.019088
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: