Provider Demographics
NPI:1598041402
Name:BRUSKOSKI, JESSICA LISA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LISA
Last Name:BRUSKOSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13423 ARIZONA ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9246
Mailing Address - Country:US
Mailing Address - Phone:219-718-9056
Mailing Address - Fax:
Practice Address - Street 1:600 GRANT ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-9985
Practice Address - Country:US
Practice Address - Phone:219-886-4405
Practice Address - Fax:219-881-8801
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IN10001374A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical