Provider Demographics
NPI:1881770378
Name:BLAIR, JESSICA ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:BLAIR
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:1720A MEDICAL PARK DR STE 150
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2135
Practice Address - Country:US
Practice Address - Phone:228-392-7429
Practice Address - Fax:228-396-3830
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00390363A00000X
TXPA04737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS006231797Medicaid
TX182326202Medicaid
TX8N9864OtherBCBS
Q64567Medicare UPIN
TXP00385857OtherRR MEDICARE