Provider Demographics
NPI:1689665622
Name:WHITE, JESSICA A (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 LOGAN AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1916
Mailing Address - Country:US
Mailing Address - Phone:319-235-3697
Mailing Address - Fax:319-235-3844
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3697
Practice Address - Fax:319-235-3844
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33899207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA24195OtherWELLMARK BC/BS IOWA
IA4240127Medicaid
IAP00207392OtherRAILROAD MEDICARE
IAI10955Medicare PIN
IA4240127Medicaid