Provider Demographics
NPI:1093048530
Name:NIEWODOWSKI, JESSICA (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NIEWODOWSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 QUEEN CITY AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-7121
Mailing Address - Country:US
Mailing Address - Phone:603-627-1102
Mailing Address - Fax:
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7121
Practice Address - Country:US
Practice Address - Phone:603-627-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60590736208600000X
PAOS015160208600000X, 2086S0102X
NH229822086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2056335Medicaid
WA2056335Medicaid