Provider Demographics
NPI:1174207732
Name:MCKINNON, JESSICA (WHNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 N SYCAMORE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5330
Mailing Address - Country:US
Mailing Address - Phone:480-559-4360
Mailing Address - Fax:
Practice Address - Street 1:580 N CAMINO MERCADO STE 8
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5757
Practice Address - Country:US
Practice Address - Phone:520-381-0380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ281456363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health