Provider Demographics
NPI:1306092028
Name:OSTROM, JESSA LOUISE (DO)
Entity type:Individual
Prefix:
First Name:JESSA
Middle Name:LOUISE
Last Name:OSTROM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2555 MARVIN RD NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2555 MARVIN RD NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3138
Practice Address - Country:US
Practice Address - Phone:360-493-4450
Practice Address - Fax:360-493-4455
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60323879207Q00000X
ORDO178828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR189584Medicare PIN