Provider Demographics
NPI:1619123049
Name:EWERT, JESSICA CLUBBS (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CLUBBS
Last Name:EWERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8965
Mailing Address - Country:US
Mailing Address - Phone:850-473-0100
Mailing Address - Fax:850-473-0500
Practice Address - Street 1:4951 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8965
Practice Address - Country:US
Practice Address - Phone:850-473-0100
Practice Address - Fax:850-473-0500
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN 10206208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics