Provider Demographics
NPI:1124654603
Name:SCANLON, JESSE L (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:L
Last Name:SCANLON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9087
Mailing Address - Country:US
Mailing Address - Phone:214-456-2331
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:844-860-6976
Practice Address - Fax:954-985-1434
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115080363A00000X
390200000X
TXPA16316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program