Provider Demographics
NPI:1588909261
Name:BAILEY, JESSICA (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:REDDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:333 N. 18TH AVENUE
Mailing Address - Street 2:SUITE #B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-2146
Mailing Address - Fax:208-232-2770
Practice Address - Street 1:333 N 18TH AVE
Practice Address - Street 2:SUITE #B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-232-2146
Practice Address - Fax:208-232-2770
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1033363A00000X
UT11280373-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant