Provider Demographics
NPI:1336300979
Name:JELLISON, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PAIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8660 W 96TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-3315
Mailing Address - Country:US
Mailing Address - Phone:913-568-0608
Mailing Address - Fax:913-213-3924
Practice Address - Street 1:8660 W 96TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-3315
Practice Address - Country:US
Practice Address - Phone:913-568-0608
Practice Address - Fax:913-213-3924
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016318207R00000X
KS04-38570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine