Healthcare Provider Details

I. General information

NPI: 1831530997
Provider Name (Legal Business Name): JESSICA LYNN BACKINGER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S BROWN ST
JACKSON MI
49203-1428
US

IV. Provider business mailing address

610 S BROWN ST
JACKSON MI
49203-1428
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-9331
  • Fax:
Mailing address:
  • Phone: 517-782-9331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901020827
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: