Provider Demographics
NPI:1770882565
Name:TELLERIA, JESSICA JEWEL MAXINE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:JEWEL MAXINE
Last Name:TELLERIA
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 1:2740 SOUTH AVE W STE 101
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-5137
Mailing Address - Country:US
Mailing Address - Phone:406-728-6101
Mailing Address - Fax:406-721-3278
Practice Address - Street 1:2740 SOUTH AVE W STE 101
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-5137
Practice Address - Country:US
Practice Address - Phone:406-728-6101
Practice Address - Fax:406-721-3278
Is Sole Proprietor?:No
Enumeration Date:2011-03-20
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT57549207X00000X
WAFT2949254207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program