Provider Demographics
NPI:1659623288
Name:MILLS, JESSICA LOUISE ALEXANDRA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE ALEXANDRA
Last Name:MILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 NEW SCOTLAND AVE
Mailing Address - Street 2:MAIL CODE 191
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-5831
Mailing Address - Fax:518-262-4223
Practice Address - Street 1:47 NEW SCOTLAND AVE
Practice Address - Street 2:MAIL CODE 191
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-5831
Practice Address - Fax:518-262-4223
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2669902086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery