Provider Demographics
NPI:1972021087
Name:JESSOP, ADREIA JENICE (ARNP, CNM, IBCLC)
Entity type:Individual
Prefix:
First Name:ADREIA
Middle Name:JENICE
Last Name:JESSOP
Suffix:
Gender:F
Credentials:ARNP, CNM, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-353-5511
Mailing Address - Fax:360-353-5502
Practice Address - Street 1:300 OAK ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626
Practice Address - Country:US
Practice Address - Phone:360-353-5511
Practice Address - Fax:360-353-5502
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00157790163WL0100X
WAAP60799447367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60799447OtherWASHINGTON STATE DEPARTMENT OF HEALTH
WA2105815Medicaid
WARN00157790OtherWASHINGTON STATE DEPARTMENT OF HEALTH