Provider Demographics
NPI:1538264775
Name:RIEDISSER, JESSICA SHELLEY (DC)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:SHELLEY
Last Name:RIEDISSER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:RENEE
Other - Last Name:SHELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1159 BRYAN RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3459
Mailing Address - Country:US
Mailing Address - Phone:636-240-8989
Mailing Address - Fax:636-240-6889
Practice Address - Street 1:1159 BRYAN RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3459
Practice Address - Country:US
Practice Address - Phone:636-240-8989
Practice Address - Fax:636-240-6889
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003006354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO185420OtherBLUE CROSS BLUE SHIELD
MO259375050OtherMEDICARE INDIVIDUAL PTAN NUMBER
MO0000259375050OtherMEDICARE INVIDICUAL PTAN, ANOTHER FORMAT
MO696970OtherACN GROUP
MO739074OtherHEALTHLINK
MO7590746OtherAETNA
MO739074OtherHEALTHLINK