Healthcare Provider Details

I. General information

NPI: 1780970442
Provider Name (Legal Business Name): JESSICA L. DESALVO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 WALNUT ST STE 950
PHILADELPHIA PA
19102-3628
US

IV. Provider business mailing address

1528 WALNUT ST STE 950
PHILADELPHIA PA
19102-3628
US

V. Phone/Fax

Practice location:
  • Phone: 267-273-1196
  • Fax: 267-273-1193
Mailing address:
  • Phone: 267-273-1196
  • Fax: 267-273-1193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOT013994
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS016649
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: