Provider Demographics
NPI:1790862076
Name:PREWITT-EMERSON, JESSICA A (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:PREWITT-EMERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 SIOUX POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049
Mailing Address - Country:US
Mailing Address - Phone:605-217-2667
Mailing Address - Fax:605-217-2900
Practice Address - Street 1:575 SIOUX POINT ROAD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-217-2667
Practice Address - Fax:605-217-2900
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0983363AS0400X
IA001882363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
255313OtherMIDLANDS CHOICE
19960OtherAVERA HEALTH PLANS
IA71758OtherBCBS IA
IAP00605701OtherRAILROAD MEDICARE
IAI11301001Medicare PIN
IAP00605701OtherRAILROAD MEDICARE