Provider Demographics
NPI:1982772612
Name:HAINES, JESSICA ANN (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:HAINES
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 1:101 ROBESON ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5520
Mailing Address - Country:US
Mailing Address - Phone:910-615-1880
Mailing Address - Fax:
Practice Address - Street 1:101 ROBESON ST
Practice Address - Street 2:SUITE 410
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5520
Practice Address - Country:US
Practice Address - Phone:910-615-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002591363A00000X
NC0010-00794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant