Provider Demographics
NPI:1588003297
Name:WILLIS, JESSICA ERIN (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ERIN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-422-0213
Mailing Address - Fax:731-784-9518
Practice Address - Street 1:3568 CHERE CAROL RD
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3639
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-784-9518
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24259207Q00000X
TN3077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine