Provider Demographics
NPI:1578721981
Name:BRANDON, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRANDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PRO RODEO DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2334
Mailing Address - Country:US
Mailing Address - Phone:719-522-0707
Mailing Address - Fax:
Practice Address - Street 1:104 PRO RODEO DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2334
Practice Address - Country:US
Practice Address - Phone:719-522-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant