Provider Demographics
NPI:1982187142
Name:SULLIVAN, JESSICA JANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JANE
Last Name:SULLIVAN
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 1:23 W PARKWAY
Mailing Address - Street 2:
Mailing Address - City:PEQUANNOCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07440-1709
Mailing Address - Country:US
Mailing Address - Phone:973-452-1290
Mailing Address - Fax:
Practice Address - Street 1:115 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2924
Practice Address - Country:US
Practice Address - Phone:973-773-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00486200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant