Provider Demographics
NPI:1407199474
Name:MCCASKILL, JESSICA LATRICE (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LATRICE
Last Name:MCCASKILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:BOSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:242 KING AVENUE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-475-1870
Mailing Address - Fax:706-475-1879
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-251-6100
Practice Address - Fax:608-260-2976
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407199474Medicaid