Provider Demographics
NPI:1033194725
Name:COLWILL, JESSICA B (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:B
Last Name:COLWILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:COLWILL
Other - Last Name:SOUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8906 SPANISH RIDGE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1319
Mailing Address - Country:US
Mailing Address - Phone:702-330-3102
Mailing Address - Fax:702-912-4994
Practice Address - Street 1:8906 SPANISH RIDGE AVE STE 202
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-1319
Practice Address - Country:US
Practice Address - Phone:702-577-1622
Practice Address - Fax:702-912-4994
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17344207V00000X, 207V00000X
VA0101244814207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA020446M03Medicare PIN