Healthcare Provider Details

I. General information

NPI: 1932440229
Provider Name (Legal Business Name): JESSICA WISS HEAVEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH ST STE 8100
PHILADELPHIA PA
19107-4824
US

IV. Provider business mailing address

3400 SPRUCE ST 1 SILVERSTEIN
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-9944
  • Fax: 215-955-9791
Mailing address:
  • Phone: 215-662-2277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA055999
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: