Healthcare Provider Details

I. General information

NPI: 1255704599
Provider Name (Legal Business Name): JESSICA E. BOGGS ANP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA E. BLAHA ANP-C

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MONTCLAIR ST
SPRINGFIELD MO
65807-5076
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-8500
  • Fax: 417-820-8532
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2015034077
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: