Provider Demographics
NPI:1396280236
Name:JESSEE, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:JESSEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 US HIGHWAY 23 N
Mailing Address - Street 2:
Mailing Address - City:WEBER CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24290-7087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3004 US HIGHWAY 23 N
Practice Address - Street 2:
Practice Address - City:WEBER CITY
Practice Address - State:VA
Practice Address - Zip Code:24290-7087
Practice Address - Country:US
Practice Address - Phone:276-386-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000036685183500000X
VA0202211507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist