Provider Demographics
NPI:1831320878
Name:LIELAND, JESSICA JO (PA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:JO
Last Name:LIELAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:AVILA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93424-0490
Mailing Address - Country:US
Mailing Address - Phone:833-527-4387
Mailing Address - Fax:805-221-6078
Practice Address - Street 1:6627 BAY LAUREL PLACE A
Practice Address - Street 2:
Practice Address - City:AVILA BEACH
Practice Address - State:CA
Practice Address - Zip Code:93424-0490
Practice Address - Country:US
Practice Address - Phone:805-540-3071
Practice Address - Fax:805-540-3072
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA20448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW7179Medicare PIN