=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194095588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANN TYLER STEVENS APNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2012
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 S WALKER ST
-----------------------------------------------------
City | ADAMS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53910-9210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-343-5165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 S WALKER ST
-----------------------------------------------------
City | ADAMS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53910-9210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-343-5165
-----------------------------------------------------
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 | 10709-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------