Provider Demographics
NPI:1730400458
Name:MEYER, JESSICA L (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MEYER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-2591
Mailing Address - Fax:920-320-4155
Practice Address - Street 1:1650 S 41ST ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-7316
Practice Address - Country:US
Practice Address - Phone:920-320-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2584-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant