Provider Demographics
NPI:1629793070
Name:PEDERSEN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 GENTRY SQUARE LN APT 106
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5973
Mailing Address - Country:US
Mailing Address - Phone:319-899-6686
Mailing Address - Fax:
Practice Address - Street 1:400 N SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:VILLA GROVE
Practice Address - State:IL
Practice Address - Zip Code:61956-9771
Practice Address - Country:US
Practice Address - Phone:217-832-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program