Provider Demographics
NPI:1578663001
Name:MACWILLIAMS, JESSICA A (PAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:MACWILLIAMS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WISTERIA LN
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2381
Mailing Address - Country:US
Mailing Address - Phone:413-364-6918
Mailing Address - Fax:860-741-2229
Practice Address - Street 1:35 WISTERIA LN
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2381
Practice Address - Country:US
Practice Address - Phone:413-364-6918
Practice Address - Fax:860-741-2229
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2497Medicare ID - Type Unspecified
MAQ53921Medicare UPIN