Provider Demographics
NPI:1871368522
Name:ESTRADA, JESSE (FNP)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 MARYVILLE UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7299
Mailing Address - Country:US
Mailing Address - Phone:188-826-6057
Mailing Address - Fax:
Practice Address - Street 1:650 MARYVILLE UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7299
Practice Address - Country:US
Practice Address - Phone:188-826-6057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5382693021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily