Provider Demographics
NPI:1417245200
Name:KWAN, JESSICA L (DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:L
Last Name:KWAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:22101 MOROSS RD
Mailing Address - Street 2:SUITE 335
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2148
Mailing Address - Country:US
Mailing Address - Phone:313-343-6393
Mailing Address - Fax:313-343-6394
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:SUITE 335
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-6393
Practice Address - Fax:313-343-6394
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5901002373213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery