Provider Demographics
NPI:1497196158
Name:OTTO, JESSICA LYNN (ARNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:OTTO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-2778
Mailing Address - Fax:
Practice Address - Street 1:3280 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-5638
Practice Address - Country:US
Practice Address - Phone:229-257-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9247352363LF0000X
FL9247352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily