Provider Demographics
NPI:1952490765
Name:GRACE, JESSICA JO (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JO
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JO
Other - Last Name:HURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4154 S RIVER RD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-2930
Mailing Address - Country:US
Mailing Address - Phone:810-329-6710
Mailing Address - Fax:810-329-8790
Practice Address - Street 1:4154 S RIVER RD BLDG 2
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2930
Practice Address - Country:US
Practice Address - Phone:810-329-6710
Practice Address - Fax:810-329-8790
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082242208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952490765Medicaid
MI4301082242OtherPHYSICIAN LICENSE