Basic Information
| Provider Information | |||||||||
| NPI: | 1003142118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | N.P. | ||||||||
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| 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: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | 4704245661 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.