Healthcare Provider Details

I. General information

NPI: 1578873154
Provider Name (Legal Business Name): JESSICA ALISON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 E 13TH ST STE 110
LOVELAND CO
80537-5134
US

IV. Provider business mailing address

2555 E 13TH ST STE 110
LOVELAND CO
80537-5134
US

V. Phone/Fax

Practice location:
  • Phone: 970-820-4264
  • Fax:
Mailing address:
  • Phone: 970-820-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: