Provider Demographics
NPI:1790003234
Name:SANDERSON, JESSICA L
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SANDERSON
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:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1519
Mailing Address - Country:US
Mailing Address - Phone:509-493-2133
Mailing Address - Fax:509-493-9544
Practice Address - Street 1:212 NE SKYLINE DR
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-1948
Practice Address - Country:US
Practice Address - Phone:509-493-2133
Practice Address - Fax:509-493-9544
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical