Provider Demographics
NPI:1407845654
Name:BORDERIEUX, JESSICA D (PA C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:D
Last Name:BORDERIEUX
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 E MARSHALL ST STE 107
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4440
Mailing Address - Country:US
Mailing Address - Phone:610-436-8440
Mailing Address - Fax:
Practice Address - Street 1:606 E MARSHALL ST STE 107
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4440
Practice Address - Country:US
Practice Address - Phone:610-439-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102515363A00000X
DEC50000622363A00000X
PAMA052540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291743200Medicaid
FL268544200Medicaid
FL268544200Medicaid
FL268544200Medicaid
DEMB2100054OtherDEA NUMBER
FLK3975Medicare ID - Type Unspecified