Healthcare Provider Details

I. General information

NPI: 1972021087
Provider Name (Legal Business Name): ADREIA JENICE JESSOP ARNP, CNM, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OAK ST
KELSO WA
98626
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-353-5511
  • Fax: 360-353-5502
Mailing address:
  • Phone: 360-353-5511
  • Fax: 360-353-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN00157790
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP60799447
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP60799447
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: