Provider Demographics
NPI:1710058342
Name:WILLARD, JESSICA SMITH (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SMITH
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:102 GREGOR MENDEL CIR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2315
Mailing Address - Country:US
Mailing Address - Phone:864-229-2663
Mailing Address - Fax:864-223-5694
Practice Address - Street 1:102 GREGOR MENDEL CIR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2315
Practice Address - Country:US
Practice Address - Phone:864-229-2663
Practice Address - Fax:864-223-5694
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1082363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0687PAMedicaid
SCAA1182Medicare UPIN
SC0687PAMedicaid