Healthcare Provider Details

I. General information

NPI: 1649659269
Provider Name (Legal Business Name): JESSA DMYTRYSZYN MSCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 WOODWARD AVE 2ND FLOOR
DETROIT MI
48201-2027
US

IV. Provider business mailing address

2304 PROGRESS AVE
LINCOLN PARK MI
48146-4808
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone: 734-626-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361003261
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: