Provider Demographics
NPI:1457870586
Name:KORTH, JESSE (NP-C)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:KORTH
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28782
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95159-8782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 N WHITE RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-1966
Practice Address - Country:US
Practice Address - Phone:866-646-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-09
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238714163WC0200X
WV87827163WC0200X
CA95028029163WC0200X
CA95012974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95012974OtherBOARD OF NURSING NP LICENSE
CA95029028OtherBOARD OF NURSING