Provider Demographics
NPI:1700354149
Name:SALO, JESSIE RAE (NP-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:RAE
Last Name:SALO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC MINE
Mailing Address - State:MI
Mailing Address - Zip Code:49905-0115
Mailing Address - Country:US
Mailing Address - Phone:906-231-3349
Mailing Address - Fax:
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1452
Practice Address - Country:US
Practice Address - Phone:906-483-1730
Practice Address - Fax:906-483-1380
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily