Provider Demographics
NPI:1417974080
Name:CRANE, JESSEE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSEE
Middle Name:
Last Name:CRANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18747 WILD HORSE FARM CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63038-1186
Mailing Address - Country:US
Mailing Address - Phone:636-458-1758
Mailing Address - Fax:
Practice Address - Street 1:233 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2219
Practice Address - Country:US
Practice Address - Phone:636-256-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6H65207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00349313OtherRR MEDICARE
MOE59573Medicare UPIN
MO959534992Medicare PIN