Provider Demographics
NPI:1104285543
Name:JESSEN, BRETT
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:JESSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10TH MEDICAL GROUP
Mailing Address - Street 2:4102 PINION DRIVE
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10TH MEDICAL GROUP
Practice Address - Street 2:4102 PINION DRIVE
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840
Practice Address - Country:US
Practice Address - Phone:801-721-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002057871223P0300X, 390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program