Provider Demographics
NPI:1902483746
Name:SHARMA, JESSICA KELLY (MAE)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KELLY
Last Name:SHARMA
Suffix:
Gender:F
Credentials:MAE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 S BLACKSPUR WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5120
Mailing Address - Country:US
Mailing Address - Phone:208-598-6595
Mailing Address - Fax:
Practice Address - Street 1:2604 S BLACKSPUR WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5120
Practice Address - Country:US
Practice Address - Phone:208-598-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician