Provider Demographics
NPI:1457758815
Name:VAN WULVEN, JESSICA D (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:VAN WULVEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:ROWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3765 E. BLUE LUPINE DR. STE D
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-707-1671
Mailing Address - Fax:907-707-1675
Practice Address - Street 1:3765 E. BLUE LUPINE DR. STE D
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-707-1671
Practice Address - Fax:907-707-1675
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2365363A00000X
AKPADA1218363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1648921Medicaid