Provider Demographics
NPI:1891222519
Name:WAITE, JESSICA (CNM)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:WAITE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3663
Mailing Address - Country:US
Mailing Address - Phone:517-281-2126
Mailing Address - Fax:
Practice Address - Street 1:40 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3663
Practice Address - Country:US
Practice Address - Phone:517-281-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276969163WE0003X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WE0003XNursing Service ProvidersRegistered NurseEmergency