Healthcare Provider Details

I. General information

NPI: 1053874792
Provider Name (Legal Business Name): JESSE LEAH KESON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 E PARKDALE AVE
MANISTEE MI
49660-9709
US

IV. Provider business mailing address

11279 QUARTERLINE RD
MANISTEE MI
49660
US

V. Phone/Fax

Practice location:
  • Phone: 231-398-1000
  • Fax:
Mailing address:
  • Phone: 231-690-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704292299
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: