Provider Demographics
NPI:1609375575
Name:HANSROTH, JESSICA CHANEY (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHANEY
Last Name:HANSROTH
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 1:527 MEDICAL PARK DR STE 401
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3570
Mailing Address - Fax:681-342-3575
Practice Address - Street 1:527 MEDICAL PARK DR STE 401
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9010
Practice Address - Country:US
Practice Address - Phone:681-342-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant