Provider Demographics
NPI:1245741636
Name:GILMORE, JESSICA A (PAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:RENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1040 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6416
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1098
Practice Address - Country:US
Practice Address - Phone:419-294-4991
Practice Address - Fax:419-209-0278
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005319RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant