Provider Demographics
NPI:1285722942
Name:DIESELDORFF, JESSICA ROSE (NP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:DIESELDORFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:MANKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1691 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2203
Mailing Address - Country:US
Mailing Address - Phone:408-795-3619
Mailing Address - Fax:408-287-0405
Practice Address - Street 1:398 S GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3099
Practice Address - Country:US
Practice Address - Phone:831-786-2008
Practice Address - Fax:831-724-7438
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548205363LW0102X
CA10442163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse