Provider Demographics
NPI:1114261617
Name:RAMON, JESSICA LARAE (IDC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LARAE
Last Name:RAMON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63062
Mailing Address - Street 2:
Mailing Address - City:MCBH KANEOHE BAY
Mailing Address - State:HI
Mailing Address - Zip Code:96863-3062
Mailing Address - Country:US
Mailing Address - Phone:808-257-1571
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:CLB-3 MCBH
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-257-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman