Provider Demographics
NPI:1295987634
Name:JUSTICE VOGT, JESSICA LEE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEE
Last Name:JUSTICE VOGT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:PPMC, TSICO
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-7320
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:PPMC, TSICO
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053625363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical