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NPI Code Detail

MEDICARE: JESSIE CAMACHO JR.

MEDICARE: JESSIE CAMACHO JR.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1175T00000XPeer Specialist

General Provider Information

NPI Number : 1487029575
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSIE CAMACHO JR.
Provider Business Mailing Address
First Line : 19436 PACKARD ST
Second Line :
City : DETROIT
State : MI
Zip : 48234-3195
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 19436 PACKARD ST
Second Line :
City : DETROIT
State : MI
Zip : 48234-3195
Country : US
Telephone Number : 313-231-6049
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/01/2015
Last Update Date : 12/01/2015

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Directions to “ JESSIE CAMACHO JR. ” Practice Location

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