Provider Demographics
NPI:1366967739
Name:ROTOLO, JESSICA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:ROTOLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:29 TAYLOR AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4536
Mailing Address - Country:US
Mailing Address - Phone:931-484-6061
Mailing Address - Fax:931-484-6062
Practice Address - Street 1:29 TAYLOR AVE STE 101
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4536
Practice Address - Country:US
Practice Address - Phone:931-484-6061
Practice Address - Fax:931-484-6062
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant