Provider Demographics
NPI:1033665500
Name:ERICKSON, JESSICA M (RDH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33805 BURNS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENT
Mailing Address - State:MN
Mailing Address - Zip Code:55947-4246
Mailing Address - Country:US
Mailing Address - Phone:612-202-7357
Mailing Address - Fax:608-782-2198
Practice Address - Street 1:2 COPELAND AVE STE 203
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3419
Practice Address - Country:US
Practice Address - Phone:608-782-4054
Practice Address - Fax:608-782-2198
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10269-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist