Provider Demographics
NPI:1295923746
Name:HUSTY, JESSICA MAE (PAC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MAE
Last Name:HUSTY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:MAE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 160448
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33116-0448
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-436-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104337363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292909100Medicaid
FLAG854ZMedicare PIN
P00464743Medicare PIN