Provider Demographics
NPI:1104288042
Name:MORMANDO, JESSICA (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MORMANDO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:OPSAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:647 DUNLOP LN STE 203
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5165
Mailing Address - Country:US
Mailing Address - Phone:931-502-3700
Mailing Address - Fax:931-502-3705
Practice Address - Street 1:647 DUNLOP LN STE 203
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5165
Practice Address - Country:US
Practice Address - Phone:931-502-3700
Practice Address - Fax:931-502-3705
Is Sole Proprietor?:No
Enumeration Date:2016-03-21
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
TNMD52396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program