Healthcare Provider Details

I. General information

NPI: 1811495674
Provider Name (Legal Business Name): OLUCHUKWU JESSICA AZUMAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-2500
  • Fax:
Mailing address:
  • Phone: 313-833-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number6803087010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: