Provider Demographics
NPI:1366015406
Name:LAO, JESSERIE JANELLE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JESSERIE
Middle Name:JANELLE
Last Name:LAO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24620 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3114
Mailing Address - Country:US
Mailing Address - Phone:313-407-8335
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:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299396367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
136556OtherNBCRNA
MI4704299396OtherBOARD OF NURSING
CA851385OtherBOARD OF NURSING