Provider Demographics
NPI:1023551249
Name:HOORT, JESSICA LEE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEE
Last Name:HOORT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:VERRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-392-8742
Mailing Address - Fax:231-935-0747
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-392-8742
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304605163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse