Provider Demographics
NPI:1174163471
Name:ASHBROOK, JESSICA SUE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:ASHBROOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-1012
Mailing Address - Country:US
Mailing Address - Phone:605-964-0706
Mailing Address - Fax:605-964-0545
Practice Address - Street 1:215 N 9TH ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1364
Practice Address - Country:US
Practice Address - Phone:314-605-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017008764163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical