Provider Demographics
NPI:1467829440
Name:ATKINSON, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ATKINSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PICINICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:5414 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1335
Practice Address - Country:US
Practice Address - Phone:903-581-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
TXPA10251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01719714OtherRAIL ROAD MEDICARE
TX351895303Medicaid
TX75-0818167-015OtherTRICARE
TX75-1976930-005OtherTRICARE
TX75-2616977-002OtherTRICARE
TX75-2616977-041OtherTRICARE
TX8627NYOtherBCBS
TX75-0818167-048OtherTRICARE
TX351895305Medicaid
TX75-0818167-022OtherTRICARE
TX75-2616977-028OtherTRICARE
TX8491NYOtherBCBS
TX8493NYOtherBCBS
TX351895304Medicaid
TX75-0818167-044OtherTRICARE
TXP01719711OtherRAIL ROAD MEDICARE
TX351895306Medicaid
TX8492NYOtherBCBS
TXP01707527OtherRAIL ROAD MEDICARE
TX75-0818167-015OtherTRICARE
TX75-2616977-002OtherTRICARE
TX351895304Medicaid
TX522744YS6VMedicare PIN