Provider Demographics
NPI:1881266153
Name:FIRESTONE, JESSICA LEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:FIRESTONE
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 1:1400 MERCY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1833
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-733-5212
Practice Address - Street 1:1400 MERCY DR STE 100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1833
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-733-5212
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN4807363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program