Provider Demographics
NPI:1447499975
Name:PHELPS, JESSE (PA-C, LAC)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PA-C, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E ROMIE LN
Mailing Address - Street 2:SUITE 12
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-4026
Mailing Address - Country:US
Mailing Address - Phone:831-758-6990
Mailing Address - Fax:408-445-0875
Practice Address - Street 1:535 E ROMIE LN
Practice Address - Street 2:SUITE 12
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4026
Practice Address - Country:US
Practice Address - Phone:831-758-6990
Practice Address - Fax:408-445-0875
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10921171100000X
CA51289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist