Provider Demographics
NPI:1831684968
Name:PERSAUD, JESSICA (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15786 BRANDT ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3211
Mailing Address - Country:US
Mailing Address - Phone:906-362-1146
Mailing Address - Fax:
Practice Address - Street 1:2751 BAY PARK DR # 300&303
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4921
Practice Address - Country:US
Practice Address - Phone:419-693-0711
Practice Address - Fax:419-693-2320
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008604363A00000X
OH50.006623RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant