Provider Demographics
NPI:1285941534
Name:KRISSOVICH, JESSA MARIE (CMT)
Entity type:Individual
Prefix:MS
First Name:JESSA
Middle Name:MARIE
Last Name:KRISSOVICH
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10792 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6007
Mailing Address - Country:US
Mailing Address - Phone:530-415-4110
Mailing Address - Fax:
Practice Address - Street 1:10792 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6007
Practice Address - Country:US
Practice Address - Phone:530-415-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV174400000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist