Healthcare Provider Details

I. General information

NPI: 1245670355
Provider Name (Legal Business Name): JESSICA MARIE MCDONALD CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARIE SELLBOM CNP

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1929
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD SUITE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-3580
  • Fax: 757-594-3653
Mailing address:
  • Phone: 757-594-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.11138-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024172656
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: