Provider Demographics
NPI:1508187949
Name:THOMASON, JESSICA LOVE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LOVE
Last Name:THOMASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4914 W PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2027
Mailing Address - Country:US
Mailing Address - Phone:262-242-2014
Mailing Address - Fax:262-242-2014
Practice Address - Street 1:4914 W PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-2027
Practice Address - Country:US
Practice Address - Phone:262-242-2014
Practice Address - Fax:262-242-2014
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25873-20207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI25873-20OtherSTATE LICENSE NUMBER
FT0491996OtherDEA NUMBER