Provider Demographics
NPI:1467067975
Name:ATIYEH, JERRICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:
Last Name:ATIYEH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JERRICA
Other - Middle Name:
Other - Last Name:CLEMENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:44200 WOODWARD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5046
Mailing Address - Country:US
Mailing Address - Phone:248-212-0678
Mailing Address - Fax:
Practice Address - Street 1:44200 WOODWARD AVE STE 101
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5046
Practice Address - Country:US
Practice Address - Phone:248-212-0678
Practice Address - Fax:248-212-0790
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010168363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical