Provider Demographics
NPI:1811545700
Name:LUSSON, JESSICA SUE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SUE
Last Name:LUSSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2481 12 3/4 AVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-8725
Mailing Address - Country:US
Mailing Address - Phone:715-205-7488
Mailing Address - Fax:
Practice Address - Street 1:1501 W STOUT ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-5001
Practice Address - Country:US
Practice Address - Phone:714-236-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002730-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist