Provider Demographics
NPI:1215260336
Name:EVERSON, JESSIKA RENEE (LMP)
Entity type:Individual
Prefix:MRS
First Name:JESSIKA
Middle Name:RENEE
Last Name:EVERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7927 LITTLEROCK RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7429
Mailing Address - Country:US
Mailing Address - Phone:360-754-2588
Mailing Address - Fax:
Practice Address - Street 1:7927 LITTLEROCK RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7429
Practice Address - Country:US
Practice Address - Phone:360-754-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist