Provider Demographics
NPI:1043686967
Name:WITT, JESSICA RAE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:WITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E MEDICAL CENTER DRIVE
Mailing Address - Street 2:UH SOUTH F-6245
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE
Practice Address - Street 2:UH SOUTH F-6245
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-615-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6561-33363L00000X
WI173937-30363L00000X
MI4351049097390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467583096OtherCLINIC NPI
WI1851477913OtherST. CLARE NPI
WI528546Medicare Oscar/Certification