Healthcare Provider Details

I. General information

NPI: 1669064846
Provider Name (Legal Business Name): MR. JAY GILLESPIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JAY GILLESPIE JR.

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 COBB ST
CADILLAC MI
49601-2588
US

IV. Provider business mailing address

520 COBB ST
CADILLAC MI
49601-2588
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-6521
  • Fax: 231-775-1366
Mailing address:
  • Phone: 231-775-6521
  • Fax: 231-876-6519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010387
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number5601010387
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: