Provider Demographics
NPI:1912436635
Name:ELLSPERMAN, JESSICA MAE (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAE
Last Name:ELLSPERMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10812 N OLD 41
Mailing Address - Street 2:
Mailing Address - City:OAKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47561-8015
Mailing Address - Country:US
Mailing Address - Phone:812-499-3465
Mailing Address - Fax:
Practice Address - Street 1:2186 N HOSPITAL BLVD # 1
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7654
Practice Address - Country:US
Practice Address - Phone:812-268-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012696B1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice