Provider Demographics
NPI:1386760122
Name:PAONESSA, JESSICA E (MD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:E
Last Name:PAONESSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ERIN
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1221 SIXTH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2359
Mailing Address - Country:US
Mailing Address - Phone:231-935-0322
Mailing Address - Fax:231-935-0334
Practice Address - Street 1:1221 SIXTH ST STE 100
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-0322
Practice Address - Fax:231-935-0334
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274692208800000X
IN01071233A208800000X
MI4301113807208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03884526Medicaid
IN201112070Medicaid
IN000000792827OtherANTHEM PIN
IN000000792827OtherANTHEM PIN