Provider Demographics
NPI:1164044327
Name:CANAAN, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CANAAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 NUTT ST APT 244
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 MERCHANTS CIR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-5260
Practice Address - Country:US
Practice Address - Phone:910-803-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant