Healthcare Provider Details

I. General information

NPI: 1992212781
Provider Name (Legal Business Name): JESSICA ROSE RINKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA ROSE DERY

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

116 FABIUS DR
TROY MI
48098-3037
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-9325
  • Fax:
Mailing address:
  • Phone: 248-535-0613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704276310
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: