Provider Demographics
NPI:1225522436
Name:PRICE, JESSICA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:PRICE
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 1:3501 W 14 MILE RD APT 13
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1685
Mailing Address - Country:US
Mailing Address - Phone:847-668-3192
Mailing Address - Fax:
Practice Address - Street 1:1010 EXECUTIVE DR STE 250
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-6137
Practice Address - Country:US
Practice Address - Phone:630-920-2350
Practice Address - Fax:630-920-2382
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008710363A00000X
IL085007105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085007105OtherIL PHYSICIAN ASSISTANT LICENSE