Basic Information
| Provider Information | |||||||||
| NPI: | 1932431756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICAL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12868 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337332868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664943 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 10TH ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248274 | ||||||||
| FaxNumber: | 7278248293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9208859 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 001896000 | 05 | FL | MEDICAID |