Individual
JESSE JAMES ANTHONY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
SOIDC
Contact information
Practice address
1ST MAR RDR BN MRR MARFORSOC, BLDG 132, CAMP LEJEUNE, NC 28542
(910) 440-2497
Mailing address
1ST MAR RDR BN MRR MARFORSOC, PCS BOX 20184, CAMP LEJEUNE, NC 28542
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03179878JA
SOCOM-ATP
—
Enumeration date
08/11/2021
Last updated
08/11/2021
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