Provider Demographics
NPI:1164650933
Name:PICKARD, JESSICA (DDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PICKARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PICKARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1202 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-1232
Mailing Address - Country:US
Mailing Address - Phone:260-925-2812
Mailing Address - Fax:260-925-2864
Practice Address - Street 1:1202 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-1232
Practice Address - Country:US
Practice Address - Phone:260-925-2812
Practice Address - Fax:260-925-2864
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4108122300000X
IN12011304A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1164650933OtherNPI