Basic Information
| Provider Information | |||||||||
| NPI: | 1447716766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1536 GLENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352263109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053964008 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2010 BROOKWOOD MEDICAL CTR DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058771930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1883 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1336101401 | 05 | AL | MEDICAID |