Provider Demographics
NPI:1720006000
Name:JESSEE-BREEDING, KRISTEN RENEE (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RENEE
Last Name:JESSEE-BREEDING
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16431 WISE STREET
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:VA
Mailing Address - Zip Code:24283
Mailing Address - Country:US
Mailing Address - Phone:276-762-2300
Mailing Address - Fax:276-762-0612
Practice Address - Street 1:16431 WISE ST.
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:VA
Practice Address - Zip Code:24283-0000
Practice Address - Country:US
Practice Address - Phone:276-762-2300
Practice Address - Fax:276-762-0612
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN01A5OtherJOHN DEERE TENNCARE
VA1720006000Medicaid
VA1720006000Medicaid