Provider Demographics
NPI:1952931966
Name:LIVENGOOD, JESSICA J (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:LIVENGOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 NEW GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2721
Mailing Address - Country:US
Mailing Address - Phone:336-268-3129
Mailing Address - Fax:
Practice Address - Street 1:1210 NEW GARDEN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2721
Practice Address - Country:US
Practice Address - Phone:336-294-6190
Practice Address - Fax:336-294-6278
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09754363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant