Healthcare Provider Details

I. General information

NPI: 1578053765
Provider Name (Legal Business Name): JESSICA V MISICH-JABIRO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA V MISICH MD

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19251 MACK AVE STE 333
GROSSE POINTE WOODS MI
48236-2898
US

IV. Provider business mailing address

19251 MACK AVE STE 333
GROSSE POINTE WOODS MI
48236-2898
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-7774
  • Fax:
Mailing address:
  • Phone: 313-343-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301115012
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301504088
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: