Provider Demographics
NPI:1669573929
Name:JAMESON, JESSICA BERRYMAN (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BERRYMAN
Last Name:JAMESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:BERRYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:1641 E POLSTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7852
Practice Address - Country:US
Practice Address - Phone:208-457-4208
Practice Address - Fax:208-457-4197
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11915207L00000X, 207LP2900X, 207LP2900X
OK25425207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669573929Medicaid