Healthcare Provider Details

I. General information

NPI: 1437380474
Provider Name (Legal Business Name): JESSICA DAVIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS ST CHARLESTON AREA MEDICAL CENTER
CHARLESTON WV
25301-1326
US

IV. Provider business mailing address

EMERGENCY DEPARTMENT 3200 MACCORKLE AVENUE SE
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-6004
  • Fax:
Mailing address:
  • Phone: 304-388-4172
  • Fax: 304-388-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1428
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: