Provider Demographics
NPI:1841549318
Name:HALL, JESSICA LOIS (PA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LOIS
Last Name:HALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23475 US HIGHWAY 270
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:OK
Mailing Address - Zip Code:74940-7228
Mailing Address - Country:US
Mailing Address - Phone:918-658-5996
Mailing Address - Fax:
Practice Address - Street 1:109 KERR AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5270
Practice Address - Country:US
Practice Address - Phone:918-649-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant