Healthcare Provider Details

I. General information

NPI: 1417565086
Provider Name (Legal Business Name): DANIELLE NEESAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PAGE AVE
JACKSON MI
49201-2419
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1234
  • Fax: 517-205-1050
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: