Provider Demographics
NPI:1710457148
Name:GUST, JESSICA KATHERINE (PA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:KATHERINE
Last Name:GUST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:703 N MCEWAN ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1440
Practice Address - Country:US
Practice Address - Phone:989-802-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008796363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant