Provider Demographics
NPI:1104289099
Name:CHILDS, JESSE ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ELIZABETH
Last Name:CHILDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:ELIZABETH
Other - Last Name:DIBRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12345 MERCY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419
Mailing Address - Country:US
Mailing Address - Phone:912-927-3046
Mailing Address - Fax:912-925-0597
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-5498
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7598363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical