Provider Demographics
NPI:1568625226
Name:GARDNER, JESSICA ELENA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ELENA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELENA
Other - Last Name:SHARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9514 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3359
Mailing Address - Country:US
Mailing Address - Phone:919-601-7707
Mailing Address - Fax:757-953-5025
Practice Address - Street 1:7021 HARBOUR VIEW BLVD STE 119
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2869
Practice Address - Country:US
Practice Address - Phone:757-953-7000
Practice Address - Fax:757-953-5025
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116021373390200000X
MO2008015974390200000X
VA0101249412208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAFG2530346OtherDEA