Provider Demographics
NPI:1457457129
Name:KRISEL, JESSICA L (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:KRISEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-0437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 RUSSELL PKWY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6164
Practice Address - Country:US
Practice Address - Phone:478-923-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA10875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200101360AMedicaid
OK242708506Medicare PIN