Provider Demographics
NPI:1912081928
Name:ITTIARA, JESSIE (PA)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:ITTIARA
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 1:2006 HOGBACK RD
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9750
Mailing Address - Country:US
Mailing Address - Phone:734-786-2317
Mailing Address - Fax:
Practice Address - Street 1:2006 HOGBACK RD
Practice Address - Street 2:SUITE 5A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9750
Practice Address - Country:US
Practice Address - Phone:734-786-2317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003513OtherMICHIGAN LICENSE
MIM10913649OtherDEA
MIP07370001Medicare ID - Type Unspecified