Provider Demographics
NPI:1184178717
Name:COLLESIDES, JESSICA R (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:COLLESIDES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-2153
Mailing Address - Country:US
Mailing Address - Phone:253-228-5654
Mailing Address - Fax:
Practice Address - Street 1:705 E HARRISON ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-2153
Practice Address - Country:US
Practice Address - Phone:253-228-5654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201601329RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse