Healthcare Provider Details

I. General information

NPI: 1013675255
Provider Name (Legal Business Name): JESSICA NICOLE MCCAIN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3396
US

IV. Provider business mailing address

1125 KINZER ST
POPLAR BLUFF MO
63901-4807
US

V. Phone/Fax

Practice location:
  • Phone: 573-776-2835
  • Fax: 573-776-2763
Mailing address:
  • Phone: 573-300-7944
  • Fax: 573-776-2763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021048428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: