Provider Demographics
NPI:1316112444
Name:WALLAERT, JESSICA B (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:WALLAERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:B
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-8193
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DHMC
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-8193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15096208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery