Provider Demographics
NPI:1164809570
Name:PERRY, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PERRY
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 1:4645 NW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4524
Mailing Address - Country:US
Mailing Address - Phone:352-375-1212
Mailing Address - Fax:352-416-0818
Practice Address - Street 1:4645 NW 8TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4524
Practice Address - Country:US
Practice Address - Phone:352-375-1212
Practice Address - Fax:352-416-0818
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015570000Medicaid
FL015570000Medicaid