Provider Demographics
NPI:1366714594
Name:HAINES, JESSICA LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:HAINES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 N HIGHWAY 66
Mailing Address - Street 2:STE B
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-3073
Mailing Address - Country:US
Mailing Address - Phone:918-266-4433
Mailing Address - Fax:918-266-4244
Practice Address - Street 1:2400 N HIGHWAY 66
Practice Address - Street 2:STE B
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-3073
Practice Address - Country:US
Practice Address - Phone:918-266-4433
Practice Address - Fax:918-266-4244
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200427800AMedicaid
OK329190YULCMedicare PIN