Provider Demographics
NPI:1396942207
Name:VANN, JESSICA UPCHURCH (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:UPCHURCH
Last Name:VANN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LOUISE
Other - Last Name:UPCHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-8593
Mailing Address - Fax:336-832-4382
Practice Address - Street 1:1200 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1004
Practice Address - Country:US
Practice Address - Phone:336-832-8593
Practice Address - Fax:336-832-4382
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2334207R00000X
NC201201499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4288791Medicare PIN
P00905982Medicare PIN