Basic Information
| Provider Information | |||||||||
| NPI: | 1881115996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARRARD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1723 42ND ST | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699100050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 505 E ALCOTT ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2902018251 | MI | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 2902018251 | 05 | MI | MEDICAID |