Provider Demographics
NPI:1720333628
Name:ANDERSON, JESSE WILLIS (RN)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:WILLIS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2789 ORTIZ AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7806
Mailing Address - Country:US
Mailing Address - Phone:239-275-3222
Mailing Address - Fax:
Practice Address - Street 1:2789 ORTIZ AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7806
Practice Address - Country:US
Practice Address - Phone:239-275-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3313792163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN 3313792OtherRN LICENSE