Provider Demographics
NPI:1629399415
Name:STROUD, JESSICA LEE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEE
Last Name:STROUD
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:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:6294 STATE HIGHWAY 154
Practice Address - Street 2:
Practice Address - City:SESSER
Practice Address - State:IL
Practice Address - Zip Code:62884-2163
Practice Address - Country:US
Practice Address - Phone:618-625-6679
Practice Address - Fax:618-625-5362
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028329122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist