Provider Demographics
NPI:1164791752
Name:TACCONELLI, JESSICA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:TACCONELLI
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:6330 ORCHARD LAKE RD.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-6330
Mailing Address - Country:US
Mailing Address - Phone:248-855-3366
Mailing Address - Fax:248-855-6213
Practice Address - Street 1:6330 ORCHARD LAKE RD.
Practice Address - Street 2:SUITE 120
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-855-3366
Practice Address - Fax:248-855-6213
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical