Provider Demographics
NPI:1063703544
Name:HARRISON, JESSICA (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HARRISON
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:PO BOX 2487
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-2487
Mailing Address - Country:US
Mailing Address - Phone:970-403-0555
Mailing Address - Fax:970-403-0556
Practice Address - Street 1:1201 MAIN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5260
Practice Address - Country:US
Practice Address - Phone:970-403-0555
Practice Address - Fax:970-403-0556
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3179OtherCOLORADO LICENSE