Healthcare Provider Details

I. General information

NPI: 1699688366
Provider Name (Legal Business Name): JESSICA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 S WAGNER RD
ANN ARBOR MI
48103-9715
US

IV. Provider business mailing address

4779 FIVE MILE RD
ANN ARBOR MI
48105-9421
US

V. Phone/Fax

Practice location:
  • Phone: 734-629-7363
  • Fax:
Mailing address:
  • Phone: 734-629-7363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101003031
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: