Healthcare Provider Details

I. General information

NPI: 1255694915
Provider Name (Legal Business Name): JESSICA ANNE KELSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA ANNE HUFFORD

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 WARNER MILNE RD
OREGON CITY OR
97045-4073
US

IV. Provider business mailing address

7105 SW HAMPTON ST
TIGARD OR
97223-8314
US

V. Phone/Fax

Practice location:
  • Phone: 503-810-0328
  • Fax:
Mailing address:
  • Phone: 503-684-9274
  • Fax: 503-624-9610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7596
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: