Healthcare Provider Details

I. General information

NPI: 1265192256
Provider Name (Legal Business Name): JESSICA ANN CROUCH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2021
Last Update Date: 12/18/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E WALNUT LAWN ST STE 200
SPRINGFIELD MO
65807-7865
US

IV. Provider business mailing address

781 S ERIC ST
SPRINGFIELD MO
65802-9405
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4450
  • Fax:
Mailing address:
  • Phone: 660-281-9076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021049828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: