Provider Demographics
NPI:1467169748
Name:HART, JESSIE PAGE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:PAGE
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10151 N ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MI
Mailing Address - Zip Code:49262-9740
Mailing Address - Country:US
Mailing Address - Phone:517-425-1212
Mailing Address - Fax:
Practice Address - Street 1:2282 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1432
Practice Address - Country:US
Practice Address - Phone:517-768-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704342268363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology