Provider Demographics
NPI:1730754375
Name:LEBRUN, JESSICA FORRY (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FORRY
Last Name:LEBRUN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FORRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:104 VESPER CIR
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2520
Mailing Address - Country:US
Mailing Address - Phone:864-560-5444
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-5444
Practice Address - Fax:864-560-6017
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC4060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant