Provider Demographics
NPI:1639540073
Name:BASSETT, JESICA ANNE
Entity Type:Individual
Prefix:
First Name:JESICA
Middle Name:ANNE
Last Name:BASSETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESICA
Other - Middle Name:
Other - Last Name:KOSSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1496 W MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1646
Mailing Address - Country:US
Mailing Address - Phone:517-231-7183
Mailing Address - Fax:
Practice Address - Street 1:888 W BIG BEAVER RD STE 780
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4745
Practice Address - Country:US
Practice Address - Phone:313-228-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098585104100000X
MI68011040751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker