Healthcare Provider Details

I. General information

NPI: 1780941831
Provider Name (Legal Business Name): JESSICA S TERRY FNP/BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 PETERS CREEK RD STE 110
ROANOKE VA
24019-4060
US

IV. Provider business mailing address

6701 PETERS CREEK RD STE 110
ROANOKE VA
24019-4060
US

V. Phone/Fax

Practice location:
  • Phone: 800-765-7130
  • Fax: 888-500-1891
Mailing address:
  • Phone: 800-765-7130
  • Fax: 888-500-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number51009
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171615
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: