=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396275376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANNA ANDERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2017
-----------------------------------------------------
Last Update Date | 06/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 539 MITCHELL AVE
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95380-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-485-2379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 539 MITCHELL AVE
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95380-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | 690909
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------