Healthcare Provider Details

I. General information

NPI: 1790139467
Provider Name (Legal Business Name): JESSIKA TARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W BIG BEAVER RD
TROY MI
48084-4900
US

IV. Provider business mailing address

755 W BIG BEAVER RD
TROY MI
48084-4900
US

V. Phone/Fax

Practice location:
  • Phone: 248-519-7911
  • Fax:
Mailing address:
  • Phone: 248-519-7911
  • Fax: 248-519-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704397931
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: