Provider Demographics
NPI:1063945400
Name:DEFFLER, JESSICA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DEFFLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 301
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:215-955-2363
Mailing Address - Fax:215-955-8600
Practice Address - Street 1:833 CHESTNUT ST STE 301
Practice Address - Street 2:SUITE 301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-7190
Practice Address - Fax:215-955-8600
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD469188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program