Provider Demographics
NPI:1053610154
Name:WILLIS, JESSICA MARIE (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9039 W END CIR
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3350
Mailing Address - Country:US
Mailing Address - Phone:304-685-5980
Mailing Address - Fax:
Practice Address - Street 1:2596 TINKLING SPRING RD
Practice Address - Street 2:
Practice Address - City:STUARTS DRAFT
Practice Address - State:VA
Practice Address - Zip Code:24477-2797
Practice Address - Country:US
Practice Address - Phone:540-337-2640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist