Provider Demographics
NPI:1033686902
Name:BOURKE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 STATE ST STE 103
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 PEACH ST STE 400
Practice Address - Street 2:SUITE 400
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1423
Practice Address - Country:US
Practice Address - Phone:814-454-8287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant