Provider Demographics
NPI:1528000759
Name:KING, JESSICA J (PA C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:KING
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 1:21600 HIGHWAY 99
Mailing Address - Street 2:SUITE 280
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8012
Mailing Address - Country:US
Mailing Address - Phone:425-774-2616
Mailing Address - Fax:425-774-2660
Practice Address - Street 1:21600 HIGHWAY 99
Practice Address - Street 2:SUITE 280
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8012
Practice Address - Country:US
Practice Address - Phone:425-774-2616
Practice Address - Fax:425-774-2660
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1594KIOtherBSWA
WA2164KIOtherBSWA
WA8348898Medicaid
WA0147109OtherLIWA
WA0171360OtherLIWA
WA1594KIOtherBSWA
WAP23316Medicare UPIN
WA970017778Medicare PIN
WA0147109OtherLIWA
WAGAB18593Medicare PIN