Healthcare Provider Details

I. General information

NPI: 1922171610
Provider Name (Legal Business Name): JESSICA LE SEVERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 SUMMIT ST SUITE 7
BATAVIA NY
14020-1645
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 697
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-344-4811
  • Fax: 585-344-4812
Mailing address:
  • Phone: 585-275-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number224394
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7901
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: