Provider Demographics
NPI:1568622389
Name:SOUTHARD, JESSICA ANNE (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANNE
Other - Last Name:BENES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7147 VISTA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-9313
Mailing Address - Country:US
Mailing Address - Phone:515-875-9925
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:1215 PLEASANT ST
Practice Address - Street 2:SUITE 608
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309
Practice Address - Country:US
Practice Address - Phone:515-241-5760
Practice Address - Fax:515-241-8161
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant