Healthcare Provider Details

I. General information

NPI: 1013586635
Provider Name (Legal Business Name): JESSICA JADE PRYOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4131
  • Fax: 336-713-0328
Mailing address:
  • Phone: 336-716-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMT222270
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2026-01595
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: