Healthcare Provider Details

I. General information

NPI: 1730760448
Provider Name (Legal Business Name): JESSICA LYNN HORTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2334 HOPPS RD
PORT HURON MI
48060-2435
US

IV. Provider business mailing address

1406 8TH ST
PORT HURON MI
48060-5804
US

V. Phone/Fax

Practice location:
  • Phone: 810-432-7049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: