Provider Demographics
NPI:1578053765
Name:MISICH-JABIRO, JESSICA V (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:V
Last Name:MISICH-JABIRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:V
Other - Last Name:MISICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19251 MACK AVE STE 333
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2898
Mailing Address - Country:US
Mailing Address - Phone:313-343-7280
Mailing Address - Fax:
Practice Address - Street 1:19251 MACK AVE STE 333
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2898
Practice Address - Country:US
Practice Address - Phone:313-343-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504088207R00000X
MI4301115012390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program