Provider Demographics
NPI:1578652913
Name:DEFRESE, JESSE G (DC)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:G
Last Name:DEFRESE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4659
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617
Mailing Address - Country:US
Mailing Address - Phone:530-758-8654
Mailing Address - Fax:530-758-8654
Practice Address - Street 1:423 F STREET
Practice Address - Street 2:SUITE 109
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-758-8654
Practice Address - Fax:530-758-8654
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC18378Medicare ID - Type Unspecified
T90079Medicare UPIN