1972980639 NPI number — MRS. JESIKA HARRELL PA-C

Table of content: MRS. JESIKA HARRELL PA-C (NPI 1972980639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972980639 NPI number — MRS. JESIKA HARRELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRELL
Provider First Name:
JESIKA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972980639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 EAST BENSON BLVD, SUITE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99623-7255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-250-2511
Provider Business Mailing Address Fax Number:
907-250-2511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 EAST BENSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-250-2511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PADA1252 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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