=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033544747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GIDDENS PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2013
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 W LINCOLN AVE
-----------------------------------------------------
City | CASEYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62232-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-310-0724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ATTN: 614835 PO BOX 1409 131 W HIGH ST. #1409
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65102-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-413-6243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 277000634
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------