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General NPI Number Information
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NPI Number | 1659914646
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Entity Type | Individual
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Provider Name | JESSICA MIKITA PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/22/2019
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Last Update Date | 06/03/2025
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Provider Practice Location Address
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Address Line | 4160 JOHN R ST STE 615
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City | DETROIT
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State | MI
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Zip | 48201-2022
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Country | US
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Telephone | 313-745-4195
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Fax |
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Provider Business Mailing Address
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Address Line | 400 MACK AVE
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City | DETROIT
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State | MI
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Zip | 48201-2136
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 024089-01
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601012966
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License Number State | MI
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