Provider Demographics
NPI:1790194629
Name:MAITLAND, JESSICA A (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:MAITLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:423 FORTRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1351
Mailing Address - Country:US
Mailing Address - Phone:844-852-9510
Mailing Address - Fax:
Practice Address - Street 1:88 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-2499
Practice Address - Country:US
Practice Address - Phone:508-828-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS71701618363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105527AMedicaid