Provider Demographics
NPI:1730612219
Name:DUNKLEY, JESSICA (PAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DUNKLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10003 WEBSTER RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN ON GAULEY
Mailing Address - State:WV
Mailing Address - Zip Code:26208-7713
Mailing Address - Country:US
Mailing Address - Phone:304-226-5725
Mailing Address - Fax:304-226-3274
Practice Address - Street 1:5150 BELFORT RD BLDG 400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6026
Practice Address - Country:US
Practice Address - Phone:904-580-4730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116727363A00000X
WV2045363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1730612219Medicaid