Provider Demographics
NPI:1649989997
Name:JELSOMENO, SOPHIA ELIZABETH
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:ELIZABETH
Last Name:JELSOMENO
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 1:16522 MELBA JEAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2912
Mailing Address - Country:US
Mailing Address - Phone:734-559-4676
Mailing Address - Fax:
Practice Address - Street 1:4953 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3260
Practice Address - Country:US
Practice Address - Phone:800-789-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist