Basic Information
Provider Information
NPI: 1003142118
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TKACH
FirstName: JESSICA
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: N.P.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2025 FORD AVE
Address2:  
City: WYANDOTTE
State: MI
PostalCode: 481922312
CountryCode: US
TelephoneNumber: 7342813080
FaxNumber: 7342818815
Practice Location
Address1: 2025 FORD AVE
Address2:  
City: WYANDOTTE
State: MI
PostalCode: 481922312
CountryCode: US
TelephoneNumber: 7342813080
FaxNumber: 7342818815
Other Information
ProviderEnumerationDate: 10/23/2009
LastUpdateDate: 10/23/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LC0200X4704245661MIY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine

No ID Information.


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