Provider Demographics
NPI:1033671532
Name:RICHARDS, JESSA ELIZABETH MILES
Entity type:Individual
Prefix:
First Name:JESSA
Middle Name:ELIZABETH MILES
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 NW 13TH ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2342
Mailing Address - Country:US
Mailing Address - Phone:561-361-4075
Mailing Address - Fax:
Practice Address - Street 1:880 NW 13TH ST STE 2B
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2342
Practice Address - Country:US
Practice Address - Phone:561-361-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9114035363A00000X
1175088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program