Healthcare Provider Details

I. General information

NPI: 1043165996
Provider Name (Legal Business Name): JESSICA DENISE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 GLENCOE HILLS DR APT 7
ANN ARBOR MI
48108-1024
US

IV. Provider business mailing address

2220 GLENCOE HILLS DR APT 7
ANN ARBOR MI
48108-1024
US

V. Phone/Fax

Practice location:
  • Phone: 989-414-9674
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberG635403139597
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: