Provider Demographics
NPI:1134196991
Name:EVANS, JESSICA E (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 ASHBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-8387
Mailing Address - Country:US
Mailing Address - Phone:903-806-7053
Mailing Address - Fax:
Practice Address - Street 1:103 W LOOP 281 STE 472
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4615
Practice Address - Country:US
Practice Address - Phone:903-212-7550
Practice Address - Fax:903-212-7557
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04523363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53866Medicare UPIN