MEDICARE: JESSICA ANNE KELSO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	126800000X	Dental Assistant		OR
2	124Q00000X	Dental Hygienist	H7596	OR

General Provider Information

NPI Number	:	1255694915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ANNE KELSO

Provider Business Mailing Address
First Line	:	7105 SW HAMPTON ST
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-8314
Country	:	US
Telephone Number	:	503-684-9274
Fax Number	:	503-624-9610

Provider Business Practice Location Address
First Line	:	365 WARNER MILNE RD
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-4073
Country	:	US
Telephone Number	:	503-810-0328
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	01/13/2020

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