Provider Demographics
NPI:1417257502
Name:PANNELL, JESSE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:ELIZABETH
Last Name:PANNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JESSE
Other - Middle Name:ELIZABETH
Other - Last Name:SISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3131 PRINCETON PIKE
Mailing Address - Street 2:STE 208
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2201
Mailing Address - Country:US
Mailing Address - Phone:609-815-7829
Mailing Address - Fax:609-815-7894
Practice Address - Street 1:750 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4143
Practice Address - Country:US
Practice Address - Phone:609-394-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-24
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054714363AM0700X
NJ25MP00251400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical