Provider Demographics
NPI:1053602052
Name:MAIRS, JESSICA ELLEN (LM, CPM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:MAIRS
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10449 NO NAME DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4509
Mailing Address - Country:US
Mailing Address - Phone:925-457-4787
Mailing Address - Fax:530-274-7655
Practice Address - Street 1:10449 NO NAME DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4509
Practice Address - Country:US
Practice Address - Phone:925-457-4787
Practice Address - Fax:530-274-7655
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM300176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife