Healthcare Provider Details

I. General information

NPI: 1760844310
Provider Name (Legal Business Name): JEDD LYN TICAR ROESSNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 LOMA DR STE 202
LOS ANGELES CA
90017-1103
US

IV. Provider business mailing address

950 S GRAND AVE FL 2
LOS ANGELES CA
90015-3999
US

V. Phone/Fax

Practice location:
  • Phone: 213-858-5126
  • Fax: 213-858-5154
Mailing address:
  • Phone: 323-669-4346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA159778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: