MEDICARE: JESSICA DUNKLEY PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9116727	FL
2	363AM0700X	Medical Physician Assistant	2045	WV

General Provider Information

NPI Number	:	1730612219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DUNKLEY PAC

Provider Business Mailing Address
First Line	:	10003 WEBSTER RD
Second Line	:
City	:	CAMDEN ON GAULEY
State	:	WV
Zip	:	26208-7713
Country	:	US
Telephone Number	:	304-226-5725
Fax Number	:	304-226-3274

Provider Business Practice Location Address
First Line	:	5150 BELFORT RD BLDG 400
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6026
Country	:	US
Telephone Number	:	904-580-4730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	11/07/2022

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