Provider Demographics
NPI:1023570538
Name:VISSER, JACQUELYN DIANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:DIANE
Last Name:VISSER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:DIANE
Other - Last Name:CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2087 CAMPUS BOX
Mailing Address - Street 2:
Mailing Address - City:ELON
Mailing Address - State:NC
Mailing Address - Zip Code:27244-2010
Mailing Address - Country:US
Mailing Address - Phone:336-278-6847
Mailing Address - Fax:
Practice Address - Street 1:1236 HUFFMAN MILL RD STE 130
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-438-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant