Provider Demographics
NPI:1487033957
Name:NISHIMORI, JESSALYN (MD)
Entity Type:Individual
Prefix:
First Name:JESSALYN
Middle Name:
Last Name:NISHIMORI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-6355
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:610-497-7520
Mailing Address - Fax:610-497-7525
Practice Address - Street 1:1260 E WOODLAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064
Practice Address - Country:US
Practice Address - Phone:610-690-4490
Practice Address - Fax:610-328-9391
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD464199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine