Provider Demographics
NPI:1689493769
Name:BRACK, JESSICA MARIE (RN)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:BRACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3202 N GREY MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-8715
Mailing Address - Country:US
Mailing Address - Phone:309-444-7181
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14140719163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse