Provider Demographics
NPI:1265593685
Name:UMLOR, JESSICA L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:UMLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:PITSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6100 NEWPORT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9235
Mailing Address - Country:US
Mailing Address - Phone:269-343-4679
Mailing Address - Fax:269-343-5929
Practice Address - Street 1:6100 NEWPORT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9235
Practice Address - Country:US
Practice Address - Phone:269-343-4679
Practice Address - Fax:269-343-5929
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56010-04622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C96019007OtherMEDICARE / PTAN
MI0N31830025Medicare PIN
Q74205Medicare UPIN