Provider Demographics
NPI:1689704074
Name:PEATROSS, JESSICA LAINE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAINE
Last Name:PEATROSS
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 1:670 MONTEREY PASS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-2436
Mailing Address - Country:US
Mailing Address - Phone:626-551-5155
Mailing Address - Fax:
Practice Address - Street 1:670 MONTEREY PASS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-2436
Practice Address - Country:US
Practice Address - Phone:626-551-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42752207R00000X
CA139872208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
107156OtherSIHO/NIS
000000624958OtherNIS/ANTHEM
000026447QOtherNIS/HUMANA
50025070OtherPHP/NIS
000000624958OtherNIS/ANTHEM
107156OtherSIHO/NIS
3730009000OtherPAD/NIS
000026447QOtherNIS/HUMANA