Provider Demographics
NPI:1255694915
Name:KELSO, JESSICA ANNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:KELSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANNE
Other - Last Name:HUFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7105 SW HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8314
Mailing Address - Country:US
Mailing Address - Phone:503-684-9274
Mailing Address - Fax:503-624-9610
Practice Address - Street 1:365 WARNER MILNE RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4073
Practice Address - Country:US
Practice Address - Phone:503-810-0328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126800000X
ORH7596124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No126800000XDental ProvidersDental Assistant