Provider Demographics
NPI:1427289222
Name:WAKS, JESSICA MARY (CNP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARY
Last Name:WAKS
Suffix:
Gender:
Credentials:CNP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:MARY
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:270 MAIN ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6788
Mailing Address - Country:US
Mailing Address - Phone:651-342-1039
Mailing Address - Fax:651-342-1428
Practice Address - Street 1:270 MAIN ST N STE 300
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6788
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:651-342-1428
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-164801-8163W00000X
MN1296363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse