Provider Demographics
NPI:1871035899
Name:BACA, JERRICA SHAYLENE
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:SHAYLENE
Last Name:BACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41521 W. 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOBI
Mailing Address - State:MI
Mailing Address - Zip Code:48375
Mailing Address - Country:US
Mailing Address - Phone:505-570-9135
Mailing Address - Fax:
Practice Address - Street 1:41521 W. 11 MILE RD NOBI
Practice Address - Street 2:
Practice Address - City:NOBI
Practice Address - State:MI
Practice Address - Zip Code:48375
Practice Address - Country:US
Practice Address - Phone:505-570-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3735825652Medicaid