Healthcare Provider Details

I. General information

NPI: 1538426663
Provider Name (Legal Business Name): JESSICA LYNN MILLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JESSICA LYNN LEATHERY

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E BROADWAY AVE
JACKSON WY
83001-8642
US

IV. Provider business mailing address

PO BOX 428
JACKSON WY
83001-0428
US

V. Phone/Fax

Practice location:
  • Phone: 307-739-7218
  • Fax: 307-739-7446
Mailing address:
  • Phone: 307-739-7218
  • Fax: 307-739-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number35590.1404
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: