Provider Demographics
NPI:1407113111
Name:PETTY, JESSICA LEA (IDC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEA
Last Name:PETTY
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20125
Mailing Address - Street 2:CLR-27 GROUP AID STATION
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0125
Mailing Address - Country:US
Mailing Address - Phone:904-240-3350
Mailing Address - Fax:
Practice Address - Street 1:194 MAREADY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-9332
Practice Address - Country:US
Practice Address - Phone:904-240-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman