Healthcare Provider Details

I. General information

NPI: 1487036513
Provider Name (Legal Business Name): JESSICA NEUROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 BOURN ST
LEWISTON MI
49756-8134
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

V. Phone/Fax

Practice location:
  • Phone: 989-786-4877
  • Fax: 989-786-2187
Mailing address:
  • Phone: 231-935-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101021563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: