Provider Demographics
NPI:1942769658
Name:NEIL, JESSICA (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NEIL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-3876
Mailing Address - Fax:
Practice Address - Street 1:8950 N KENDALL DR STE 410W
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2127
Practice Address - Country:US
Practice Address - Phone:786-596-3876
Practice Address - Fax:786-533-9989
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114431363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL0C3COtherBCBS
FL111052100Medicaid