Provider Demographics
NPI:1912590688
Name:MCNEILL, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCNEILL
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 1:3230 HOFFMEYER RD UNIT 10204
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-7216
Mailing Address - Country:US
Mailing Address - Phone:803-983-0055
Mailing Address - Fax:
Practice Address - Street 1:755 HIGHLAND OAKS DR STE 105
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7106
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001011005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant