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General NPI Number Information
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NPI Number | 1508549742
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Entity Type | Individual
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Provider Name | JESSICA YVONNE SALAKSANA APRN
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Gender | Female
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Dates
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Enumeration Date | 08/14/2023
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Last Update Date | 10/13/2023
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Provider Practice Location Address
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Address Line | 214 CENTERVIEW DR
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City | BRENTWOOD
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State | TN
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Zip | 37027-5274
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Country | US
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Telephone | 913-222-8425
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Fax |
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Provider Business Mailing Address
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Address Line | 565 LAKEVIEW PKWY STE 104
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City | VERNON HILLS
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State | IL
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Zip | 60061-1822
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Country | US
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Telephone | 224-998-5450
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209028021
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License Number State | IL
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