Provider Demographics
NPI:1427499862
Name:ANDERSON, JESSICA ROSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:HIATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-9300
Mailing Address - Fax:704-302-9301
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 4100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-302-9300
Practice Address - Fax:704-302-9301
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001004358363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1427499862Medicaid
SC1690PAMedicaid
SC1690PAMedicaid