Provider Demographics
NPI:1194106674
Name:DOUTAZ, JESSICA J (MS, AGNP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:J
Last Name:DOUTAZ
Suffix:
Gender:F
Credentials:MS, AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 W WADE HAMPTON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1311
Mailing Address - Country:US
Mailing Address - Phone:864-655-6615
Mailing Address - Fax:855-617-4423
Practice Address - Street 1:805 W WADE HAMPTON BLVD STE C
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1311
Practice Address - Country:US
Practice Address - Phone:864-655-6615
Practice Address - Fax:855-617-4423
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24954363LA2200X, 363LA2200X
IN28185304A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201312910Medicaid
IN000000958558OtherANTHEM PROVIDER NUMBER
INP01629408Medicare PIN
IN201312910Medicaid