Provider Demographics
NPI:1508528290
Name:TERHORST, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TERHORST
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 1:31 AMHERST RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT RIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48069-1204
Mailing Address - Country:US
Mailing Address - Phone:616-481-5830
Mailing Address - Fax:
Practice Address - Street 1:31 AMHERST RD
Practice Address - Street 2:
Practice Address - City:PLEASANT RIDGE
Practice Address - State:MI
Practice Address - Zip Code:48069-1204
Practice Address - Country:US
Practice Address - Phone:616-481-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294630363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner