Provider Demographics
NPI:1629717665
Name:NIELSEN, JESSIE SHORE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:SHORE
Last Name:NIELSEN
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 1:1931 N CLEVELAND ST APT 300
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-4116
Mailing Address - Country:US
Mailing Address - Phone:571-429-0240
Mailing Address - Fax:
Practice Address - Street 1:900 23RD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-2342
Practice Address - Country:US
Practice Address - Phone:202-715-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-28
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA200001493363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical