Provider Demographics
NPI:1972896694
Name:POULIN, JESSICA R (MD)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:R
Last Name:POULIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:770 NORTHPOINT PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1901
Mailing Address - Country:US
Mailing Address - Phone:561-275-7604
Mailing Address - Fax:561-802-5385
Practice Address - Street 1:2979 PGA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-626-3800
Practice Address - Fax:561-624-6364
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN15983207V00000X
FLME119737207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015052200Medicaid
FLIE954ZMedicare PIN