Provider Demographics
NPI:1982190450
Name:AMEZQUITA, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AMEZQUITA
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 1:6275 SCHAEFER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2210
Mailing Address - Country:US
Mailing Address - Phone:313-652-6701
Mailing Address - Fax:
Practice Address - Street 1:6275 SCHAEFER RD STE 105
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2210
Practice Address - Country:US
Practice Address - Phone:313-652-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty