Healthcare Provider Details

I. General information

NPI: 1194231597
Provider Name (Legal Business Name): JESSICA ELIZABETH MINCHELLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36555 26 MILE RD
LENOX MI
48048-3185
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 947-523-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601011787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: