Healthcare Provider Details

I. General information

NPI: 1609490689
Provider Name (Legal Business Name): JESSICA SASSINE ISHO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA AKL

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 248-909-9886
  • Fax:
Mailing address:
  • Phone: 313-876-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009968
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: