Provider Demographics
NPI:1467187187
Name:HATHAWAY, JESSAMY (PA)
Entity type:Individual
Prefix:
First Name:JESSAMY
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:265 WESTERN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2458
Mailing Address - Country:US
Mailing Address - Phone:207-661-0200
Mailing Address - Fax:207-661-0299
Practice Address - Street 1:265 WESTERN AVE STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2458
Practice Address - Country:US
Practice Address - Phone:207-661-0200
Practice Address - Fax:207-661-0299
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEPA2528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant