Provider Demographics
NPI:1942572219
Name:BERG, JESSICA HANSON (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HANSON
Last Name:BERG
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79101-3604
Mailing Address - Country:US
Mailing Address - Phone:806-378-9090
Mailing Address - Fax:
Practice Address - Street 1:808 S BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79101-3604
Practice Address - Country:US
Practice Address - Phone:806-378-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant