Provider Demographics
NPI:1215232830
Name:SHORES, JESSICA E (IDC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:SHORES
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ACCESS RD BLDG 2026
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-4485
Mailing Address - Country:US
Mailing Address - Phone:228-935-3361
Mailing Address - Fax:
Practice Address - Street 1:1000 ACCESS RD BLDG 2026
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-935-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman