Provider Demographics
NPI:1588117410
Name:SIX, JESSICA RENEE (FNP BC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RENEE
Last Name:SIX
Suffix:
Gender:F
Credentials:FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3652
Mailing Address - Country:US
Mailing Address - Phone:208-743-8416
Mailing Address - Fax:208-743-4642
Practice Address - Street 1:1522 17TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3652
Practice Address - Country:US
Practice Address - Phone:208-743-8416
Practice Address - Fax:208-743-4642
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID41058163W00000X, 390200000X
KS14-130843-081163W00000X
MARN2293625163W00000X
NJ26NR17790800163W00000X
OR201401541RN163W00000X
VT026.0100511163W00000X
WARN60300791163W00000X
ID54328363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1558452268OtherNPI
ID820394208OtherTID