Provider Demographics
NPI:1700932860
Name:MACDOUGALL, JESSICA M (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 DAVISBURG ROAD
Mailing Address - Street 2:
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350
Mailing Address - Country:US
Mailing Address - Phone:248-722-2550
Mailing Address - Fax:
Practice Address - Street 1:2221 LIVERNOIS ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-362-3500
Practice Address - Fax:248-362-1941
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003859207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON53730Medicare ID - Type Unspecified