Provider Demographics
NPI:1558425637
Name:SWANSON, JESSICA LEE
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5505 NORTH CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806
Mailing Address - Country:US
Mailing Address - Phone:563-242-4917
Mailing Address - Fax:
Practice Address - Street 1:1801 MANUFACTURING DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-6730
Practice Address - Country:US
Practice Address - Phone:563-242-4917
Practice Address - Fax:563-242-4943
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice