Healthcare Provider Details

I. General information

NPI: 1013994011
Provider Name (Legal Business Name): JESSICA S DAVIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/21/2022
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 PROVIDENCE PARK DR E FL 2
MOBILE AL
36695
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 251-631-3570
  • Fax: 251-631-3572
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA431
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA431
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: