Provider Demographics
NPI:1144588450
Name:NOLES, JESSICA JENSINE (MT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JENSINE
Last Name:NOLES
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8275 CLOVERLAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-3227
Mailing Address - Country:US
Mailing Address - Phone:313-974-1397
Mailing Address - Fax:
Practice Address - Street 1:14211 NORTHLAWN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2434
Practice Address - Country:US
Practice Address - Phone:313-974-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist