Provider Demographics
NPI:1083865398
Name:HUMPHREY, JESSICA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:31360 NORTHWESTERN HWY
Mailing Address - Street 2:WENDY SADOFF MD DERMATOLOGY PC
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334
Mailing Address - Country:US
Mailing Address - Phone:248-855-3300
Mailing Address - Fax:248-855-3319
Practice Address - Street 1:15540 BEECH DALY RD
Practice Address - Street 2:MIDWEST URGENT CARE
Practice Address - City:REDFORD TWP
Practice Address - State:MI
Practice Address - Zip Code:48239
Practice Address - Country:US
Practice Address - Phone:313-592-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2014-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005400363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF25578Medicare UPIN