Provider Demographics
NPI:1417134487
Name:JESUE, TAMMY LYNN (OT)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:LYNN
Last Name:JESUE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33555 HURON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-9145
Mailing Address - Country:US
Mailing Address - Phone:734-362-8709
Mailing Address - Fax:
Practice Address - Street 1:17197 N LAUREL PARK DR STE 555
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2686
Practice Address - Country:US
Practice Address - Phone:734-779-9700
Practice Address - Fax:734-779-9799
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1136816225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist