Provider Demographics
NPI:1417155482
Name:WORTHINGTON, JESSICA LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 MEDICAL DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2916
Mailing Address - Country:US
Mailing Address - Phone:317-575-0200
Mailing Address - Fax:317-575-0202
Practice Address - Street 1:370 MEDICAL DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2916
Practice Address - Country:US
Practice Address - Phone:317-575-0200
Practice Address - Fax:317-575-0202
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027436122300000X
IN12011279A1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist