Healthcare Provider Details

I. General information

NPI: 1356601264
Provider Name (Legal Business Name): JESSICA LYNN GARDNER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 N 8TH ST
GRAND JUNCTION CO
81501-8845
US

IV. Provider business mailing address

2525 N 8TH ST
GRAND JUNCTION CO
81501-8845
US

V. Phone/Fax

Practice location:
  • Phone: 970-255-1111
  • Fax: 970-241-5555
Mailing address:
  • Phone: 970-255-1111
  • Fax: 970-241-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-906561
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: