Healthcare Provider Details

I. General information

NPI: 1780147736
Provider Name (Legal Business Name): JESSICA ROSSKAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS022874
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: