Provider Demographics
NPI:1790310589
Name:SULLIVAN, JESSIE LYNN (RN)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17160 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:NUNICA
Mailing Address - State:MI
Mailing Address - Zip Code:49448-9450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 ORCHARD VISTA DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7069
Practice Address - Country:US
Practice Address - Phone:616-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704301679163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse