Healthcare Provider Details

I. General information

NPI: 1851972053
Provider Name (Legal Business Name): JESSICA L NEW DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 ST. ANTOINE UHC-9C
DETROIT MI
48201-2153
US

IV. Provider business mailing address

3439 WOODWARD AVE APT 243
DETROIT MI
48201-2793
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5437
  • Fax:
Mailing address:
  • Phone: 517-648-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101028041
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: