Provider Demographics
NPI:1861021784
Name:CHARLES-LAROSE, JESSICA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANNE
Last Name:CHARLES-LAROSE
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 1:15 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5736
Mailing Address - Country:US
Mailing Address - Phone:207-626-1561
Mailing Address - Fax:207-626-1849
Practice Address - Street 1:15 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5736
Practice Address - Country:US
Practice Address - Phone:207-626-1561
Practice Address - Fax:207-626-1849
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
64272390200000X
MEEC221041390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program