Provider Demographics
NPI:1457799009
Name:DOUGLASS, JESSICA A
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:MICHAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 74
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8481
Mailing Address - Fax:269-341-7781
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704271777163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse