Provider Demographics
NPI:1801670815
Name:PHELPS, JESSE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:PHELPS
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 1:4701 MEGILL RD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-6923
Mailing Address - Country:US
Mailing Address - Phone:732-856-2378
Mailing Address - Fax:
Practice Address - Street 1:2391 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-2532
Practice Address - Country:US
Practice Address - Phone:848-488-2200
Practice Address - Fax:848-300-5194
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00804100363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant