Provider Demographics
NPI:1780842385
Name:GOREHAM-VOSS, JESSICA DALE (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DALE
Last Name:GOREHAM-VOSS
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 1:4050 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2522
Mailing Address - Country:US
Mailing Address - Phone:319-631-5548
Mailing Address - Fax:
Practice Address - Street 1:4050 COON RAPIDS BLVD NW
Practice Address - Street 2:ROUTING 51400
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2522
Practice Address - Country:US
Practice Address - Phone:763-236-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8329208000000X
MN105484208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics