Provider Demographics
NPI:1689495335
Name:TAR, JESSICA (FNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TAR
Suffix:
Gender:F
Credentials:FNP-BC
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 105
Mailing Address - Street 2:
Mailing Address - City:BIG INDIAN
Mailing Address - State:NY
Mailing Address - Zip Code:12410-0105
Mailing Address - Country:US
Mailing Address - Phone:845-389-0540
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 105
Practice Address - Street 2:
Practice Address - City:BIG INDIAN
Practice Address - State:NY
Practice Address - Zip Code:12410-0105
Practice Address - Country:US
Practice Address - Phone:845-389-0540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF354588-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily