Provider Demographics
NPI:1316902398
Name:ALLEN, JESSICA KRISTEN (PAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KRISTEN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:4709 CREEKSTONE DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8411
Practice Address - Country:US
Practice Address - Phone:919-684-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051444363AS0400X
NC0010-02822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP95020Medicare UPIN