Provider Demographics
NPI:1275290330
Name:WILLIS, JESSICA CAMILLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CAMILLE
Last Name:WILLIS
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 1:5667 MAPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-7741
Mailing Address - Country:US
Mailing Address - Phone:614-596-0361
Mailing Address - Fax:
Practice Address - Street 1:2238 S HAMILTON RD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4382
Practice Address - Country:US
Practice Address - Phone:614-751-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program