Provider Demographics
NPI:1629717665
Name:NIELSEN, JESSIE SHORE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:SHORE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 N CLEVELAND ST APT 300
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-4116
Mailing Address - Country:US
Mailing Address - Phone:571-429-0240
Mailing Address - Fax:
Practice Address - Street 1:6311 RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-6410
Practice Address - Country:US
Practice Address - Phone:703-647-6087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009969363A00000X
DCPA200001493363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical