Provider Demographics
NPI:1003940966
Name:GHAFERI, JESSICA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MARIE
Last Name:GHAFERI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 230457
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-0457
Mailing Address - Country:US
Mailing Address - Phone:503-906-7300
Mailing Address - Fax:503-245-8219
Practice Address - Street 1:3131 S STATE ST STE 309
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1658
Practice Address - Country:US
Practice Address - Phone:503-906-7300
Practice Address - Fax:503-245-8219
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087739207N00000X, 207ZD0900X, 207ND0900X
ORMD174001207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609995125Medicare NSC
MIOH16156Medicare Oscar/Certification