Healthcare Provider Details

I. General information

NPI: 1750941464
Provider Name (Legal Business Name): JESSICA SUE JAYCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N GURLEY AVE
GILLETTE WY
82716-2109
US

IV. Provider business mailing address

3109 RIDGECREST DR
GILLETTE WY
82718-6009
US

V. Phone/Fax

Practice location:
  • Phone: 307-686-0669
  • Fax:
Mailing address:
  • Phone: 307-760-6219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW-306
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: