MEDICARE: JESSICA VAN WALLEGHEM

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
1	225X00000X	Occupational Therapist	12478682-4201	MI

General Provider Information

NPI Number	:	1649836271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA VAN WALLEGHEM

Provider Business Mailing Address
First Line	:	409 BELANGER ST
Second Line	:
City	:	GROSSE POINTE FARMS
State	:	MI
Zip	:	48236-3201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16137 LEONE DR
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4063
Country	:	US
Telephone Number	:	586-566-0326
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	04/08/2026

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