Provider Demographics
NPI:1124657184
Name:FILOSA, JESSICA DANIELLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:FILOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11647 E COUNTY ROAD 700 N
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-8408
Mailing Address - Country:US
Mailing Address - Phone:812-569-1111
Mailing Address - Fax:
Practice Address - Street 1:5232 SUNSET BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9347
Practice Address - Country:US
Practice Address - Phone:803-626-0294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013436A122300000X
390200000X
SC9822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program