Provider Demographics
NPI:1922585488
Name:HALLORAN, JESSICA M (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:HALLORAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:NEUMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11125 DUNN RD STE 301
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-953-8250
Mailing Address - Fax:314-953-8255
Practice Address - Street 1:11125 DUNN RD STE 301
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-953-8250
Practice Address - Fax:314-953-8255
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018027049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant