Provider Demographics
NPI:1841587029
Name:ALTIS, JESSICA HELEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:HELEN
Last Name:ALTIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:HELEN
Other - Last Name:BURKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11211 W LINCOLN AVE
Mailing Address - Street 2:LINCOLN AVENUE CLINIC
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1035
Mailing Address - Country:US
Mailing Address - Phone:414-955-5900
Mailing Address - Fax:414-327-7639
Practice Address - Street 1:11211 W LINCOLN AVE
Practice Address - Street 2:LINCOLN AVENUE CLINIC
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1035
Practice Address - Country:US
Practice Address - Phone:414-955-5900
Practice Address - Fax:414-327-7639
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI278623363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1841587029Medicaid
WI1841587029Medicaid
WI736012439Medicare PIN