Provider Demographics
NPI:1760844310
Name:ROESSNER, JEDD LYN TICAR (MD)
Entity Type:Individual
Prefix:DR
First Name:JEDD LYN
Middle Name:TICAR
Last Name:ROESSNER
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 1:950 S GRAND AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3999
Mailing Address - Country:US
Mailing Address - Phone:323-669-4346
Mailing Address - Fax:
Practice Address - Street 1:303 LOMA DR STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1103
Practice Address - Country:US
Practice Address - Phone:213-858-5126
Practice Address - Fax:213-858-5154
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA159778208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics