Provider Demographics
NPI:1942581558
Name:ROBERTS, JESSICA MILLER (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MILLER
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LINDSAY
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1122 LADY ST OFC 266
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3490
Mailing Address - Country:US
Mailing Address - Phone:888-803-3370
Mailing Address - Fax:
Practice Address - Street 1:1122 LADY ST OFC 266
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3490
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054783363A00000X
OH50.004225363A00000X
CAPA66333363A00000X
UT13578808-1206363A00000X
VA0110009664363A00000X
SC2597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115927Medicaid
OHH426230Medicare PIN
OH0115927Medicaid