Provider Demographics
NPI:1790166494
Name:LEPAGE, JACEY ANE (MD)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:ANE
Last Name:LEPAGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACEY
Other - Middle Name:ANE
Other - Last Name:LOBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:22101 MOROSS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086554A2086S0127X
MI4301107377390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program