Healthcare Provider Details

I. General information

NPI: 1255895355
Provider Name (Legal Business Name): JESSICA LYNN KATA CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LYNN ROGERS

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19229 MACK AVE STE 28
GROSSE POINTE WOODS MI
48236-2857
US

IV. Provider business mailing address

28235 DELTON ST
MADISON HEIGHTS MI
48071-2822
US

V. Phone/Fax

Practice location:
  • Phone: 313-647-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704256354
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: