Provider Demographics
NPI:1619382744
Name:EDE, JESSICA LAUREN (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LAUREN
Last Name:EDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62043 COLLEEN CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094-1000
Mailing Address - Country:US
Mailing Address - Phone:248-225-1556
Mailing Address - Fax:
Practice Address - Street 1:2605 HARLEM RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4018
Practice Address - Country:US
Practice Address - Phone:716-891-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289530207P00000X
IL125065518390200000X
MI4301113955207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program