Provider Demographics
NPI:1114101508
Name:CHI, JESSICA LAUREN (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:CHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 S AVENUE B APT 1714
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8825
Mailing Address - Country:US
Mailing Address - Phone:985-381-2231
Mailing Address - Fax:
Practice Address - Street 1:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - Street 2:BLDG H 2005 KNIGHT LANE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:928-269-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56647122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist