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 STE M-302
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5357
Practice Address - Country:US
Practice Address - Phone:269-349-2266
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704271777363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health