Provider Demographics
NPI:1518462548
Name:ADDIS, JESSE (DO)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ADDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9905 WICKER PARK PL
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-1108
Mailing Address - Country:US
Mailing Address - Phone:312-625-1041
Mailing Address - Fax:
Practice Address - Street 1:12920 SUMMERFIELD CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-7210
Practice Address - Country:US
Practice Address - Phone:813-998-8698
Practice Address - Fax:312-312-7708
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS164862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry