Provider Demographics
NPI:1649659269
Name:DMYTRYSZYN, JESSA (MSCP)
Entity type:Individual
Prefix:
First Name:JESSA
Middle Name:
Last Name:DMYTRYSZYN
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 PROGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-4808
Mailing Address - Country:US
Mailing Address - Phone:734-626-1824
Mailing Address - Fax:
Practice Address - Street 1:4160 WOODWARD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2027
Practice Address - Country:US
Practice Address - Phone:313-656-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361003261103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical