MEDICARE: JESSIKA DAWN RICO RDHAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	125K00000X	Advanced Practice Dental Therapist	1216	CA

General Provider Information

NPI Number	:	1649125105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIKA DAWN RICO RDHAP

Provider Business Mailing Address
First Line	:	2819 W MARCH LN STE B6
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-8211
Country	:	US
Telephone Number	:	209-351-6706
Fax Number	:

Provider Business Practice Location Address
First Line	:	2819 W MARCH LN STE B6
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-8211
Country	:	US
Telephone Number	:	209-351-6706
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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