Provider Demographics
NPI:1124493200
Name:ROBINSON, JESSICA BANNISTER (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BANNISTER
Last Name:ROBINSON
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 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:
Practice Address - Street 1:12 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2925
Practice Address - Country:US
Practice Address - Phone:803-433-4124
Practice Address - Fax:803-433-4230
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2446PAMedicaid