Provider Demographics
NPI:1518223494
Name:SOUTHWOOD, JESSICA ELLEN (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:SOUTHWOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELLEN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2880 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2457
Mailing Address - Country:US
Mailing Address - Phone:251-473-1900
Mailing Address - Fax:251-470-8940
Practice Address - Street 1:2880 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-2457
Practice Address - Country:US
Practice Address - Phone:251-473-1900
Practice Address - Fax:251-470-8940
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA146462207Y00000X
WI61337207Y00000X
AL45233207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1518223494Medicaid