MEDICARE: JESSICA RUTH SUTHERLAND FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704334306	MI

General Provider Information

NPI Number	:	1396471280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RUTH SUTHERLAND FNP

Provider Business Mailing Address
First Line	:	PO BOX 430150
Second Line	:
City	:	PONTIAC
State	:	MI
Zip	:	48343-0150
Country	:	US
Telephone Number	:	248-334-4962
Fax Number	:	248-724-7489

Provider Business Practice Location Address
First Line	:	1701 BALDWIN AVE
Second Line	:
City	:	PONTIAC
State	:	MI
Zip	:	48340-3412
Country	:	US
Telephone Number	:	248-334-4962
Fax Number	:	248-724-7489

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	12/12/2025

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