Healthcare Provider Details

I. General information

NPI: 1437011954
Provider Name (Legal Business Name): JESSE HAMILTON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17414 NICK DR
MACOMB MI
48044-1669
US

IV. Provider business mailing address

18968 BRIARWOOD LN
CLINTON TOWNSHIP MI
48036-2117
US

V. Phone/Fax

Practice location:
  • Phone: 313-631-3360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: