Provider Demographics
NPI:1962046961
Name:RICHARDS, JESSICA LEE (RN, MSN, CPNP-AC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:RN, MSN, CPNP-AC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:CORWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6433 PERNOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2043
Mailing Address - Country:US
Mailing Address - Phone:314-800-8041
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1081
Practice Address - Country:US
Practice Address - Phone:314-454-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014036569364SP0200X
MO2019040759363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics