Healthcare Provider Details

I. General information

NPI: 1417929910
Provider Name (Legal Business Name): JESSICA THIBODEAU APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MOUNT EUSTIS RD
LITTLETON NH
03561-3712
US

IV. Provider business mailing address

41 LINCOLN AVE
LISBON NH
03585-6508
US

V. Phone/Fax

Practice location:
  • Phone: 603-444-2464
  • Fax: 603-444-3441
Mailing address:
  • Phone: 603-838-8967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0417842305
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: