Provider Demographics
NPI:1578046603
Name:DIJULIO, JESSICA BLAIR (MA, MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BLAIR
Last Name:DIJULIO
Suffix:
Gender:F
Credentials:MA, MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 740
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4409
Mailing Address - Country:US
Mailing Address - Phone:215-955-6680
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:484-951-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060109207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOA004607OtherSTATE BOARD OF OSTEOPATHIC MEDICINE LICENSE
PAMA060109OtherSTATE BOARD OF MEDICINE LICENSE