Provider Demographics
NPI:1285143891
Name:VANDERHAM, JESSICA M (CNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:VANDERHAM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:RIPLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6915 VILLAGE MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8002
Mailing Address - Country:US
Mailing Address - Phone:336-893-1000
Mailing Address - Fax:
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001277363LF0000X
NC5017905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily