Provider Demographics
NPI:1629550512
Name:POWELL, JESSICA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4520 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8148
Mailing Address - Country:US
Mailing Address - Phone:605-977-5000
Mailing Address - Fax:605-977-5377
Practice Address - Street 1:4520 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8148
Practice Address - Country:US
Practice Address - Phone:605-977-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical