Provider Demographics
NPI:1235699661
Name:LI EASON, JESSICA KINYEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KINYEN
Last Name:LI EASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KINYEN
Other - Last Name:LI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW STE 302
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2465
Practice Address - Country:US
Practice Address - Phone:540-981-7653
Practice Address - Fax:540-981-7469
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82587207Q00000X
VA0101278496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine