Provider Demographics
NPI:1912244930
Name:GILLISPIE, JESSICA SPENCER (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SPENCER
Last Name:GILLISPIE
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 1:16 WALNUT AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4719
Mailing Address - Country:US
Mailing Address - Phone:540-345-6468
Mailing Address - Fax:540-345-3204
Practice Address - Street 1:16 WALNUT AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4719
Practice Address - Country:US
Practice Address - Phone:540-345-6468
Practice Address - Fax:540-345-3204
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant