=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386344612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA MARIE GARCIA DNP-PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 E DIVISION ST
-----------------------------------------------------
City | FOND DU LAC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54935-4560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-926-8420
-----------------------------------------------------
Fax | 920-926-8913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 MARY ANN RD APT 7
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53916-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-353-5689
-----------------------------------------------------
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 | 13686-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------