Provider Demographics
NPI:1003179532
Name:ST. JOHN, JESSICA HART (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HART
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 WAKE FOREST RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27109-6000
Mailing Address - Country:US
Mailing Address - Phone:336-758-5218
Mailing Address - Fax:
Practice Address - Street 1:1834 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27109-6000
Practice Address - Country:US
Practice Address - Phone:336-758-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL34760207Q00000X
CODR.0060018207Q00000X
NC2016-00535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine