Basic Information
| Provider Information | |||||||||
| NPI: | 1467829440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATKINSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PICINICH | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5414 S BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757031335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035811601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2015 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 8492NY | 01 | TX | BCBS | OTHER | 75-0818167-044 | 01 | TX | TRICARE | OTHER | 75-0818167-048 | 01 | TX | TRICARE | OTHER | P01707527 | 01 | TX | RAIL ROAD MEDICARE | OTHER | P01719711 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 351895303 | 05 | TX | MEDICAID | 351895306 | 05 | TX | MEDICAID | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 75-1976930-005 | 01 | TX | TRICARE | OTHER | 8491NY | 01 | TX | BCBS | OTHER | 8627NY | 01 | TX | BCBS | OTHER | 351895304 | 05 | TX | MEDICAID | 351895305 | 05 | TX | MEDICAID | 75-0818167-022 | 01 | TX | TRICARE | OTHER | P01719714 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 75-2616977-041 | 01 | TX | TRICARE | OTHER | 8493NY | 01 | TX | BCBS | OTHER |