Provider Demographics
NPI:1518336932
Name:PAYNE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PAYNE
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 1:48041 S INTERSTATE 94 SERVICE DR
Mailing Address - Street 2:APT 301
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1785
Mailing Address - Country:US
Mailing Address - Phone:937-409-8645
Mailing Address - Fax:
Practice Address - Street 1:48041 S INTERSTATE 94 SERVICE DR
Practice Address - Street 2:APT 301
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-1785
Practice Address - Country:US
Practice Address - Phone:937-409-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115594164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse