Provider Demographics
NPI:1093347072
Name:ANSARA, JESSICA EMIL
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:EMIL
Last Name:ANSARA
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 1:22384 ANTLER DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4811
Mailing Address - Country:US
Mailing Address - Phone:248-767-9902
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009725363AM0700X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology