Basic Information
| Provider Information | |||||||||
| NPI: | 1922171610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEVERSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 697 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852757546 | ||||||||
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| Practice Location | |||||||||
| Address1: | 229 SUMMIT ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140201645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853444811 | ||||||||
| FaxNumber: | 5853444812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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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 | 207N00000X | 224394 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 7901 | ND | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 000919915002 | 01 | NY | COMMUNITY BLUE | OTHER | 00025998201 | 01 | NY | UNIVERA | OTHER | 7851362 | 01 | NY | AETNA INSURANCE | OTHER | G0183268190 | 01 | NY | BLUE CHOICE GROUP NUMBER | OTHER | P010224394 | 01 | NY | BLUE CHOICE | OTHER | 2200273 | 01 | NY | GHI | OTHER | 109598 | 01 | NY | PREFERRED CARE | OTHER | 000919915002 | 01 | NY | BLUE CROSS OF WNY | OTHER | 0311421 | 01 | NY | INDEPENDENT HEALTH | OTHER | P010224394 | 01 | NY | ROCHESTER BLUE CROSS | OTHER |