Provider Demographics
NPI:1982687117
Name:VANDEVEN, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VANDEVEN
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 1:2754 NC HIGHWAY 68 S STE 111
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-8382
Mailing Address - Country:US
Mailing Address - Phone:336-802-1111
Mailing Address - Fax:336-803-7136
Practice Address - Street 1:2754 NC-68
Practice Address - Street 2:SUITE 111
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265
Practice Address - Country:US
Practice Address - Phone:336-802-1111
Practice Address - Fax:336-803-7136
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051324363AM0700X
NC0010-08044208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ14254Medicare UPIN