Provider Demographics
NPI:1386393213
Name:MODISETTE, JESSICA DENISE (APRN)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DENISE
Last Name:MODISETTE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:707 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5545
Mailing Address - Country:US
Mailing Address - Phone:903-315-5400
Mailing Address - Fax:
Practice Address - Street 1:707 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5545
Practice Address - Country:US
Practice Address - Phone:903-315-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX833036163W00000X
TX1073260363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner