Provider Demographics
NPI:1982133765
Name:ANTHONY, JESSECA (NURSE)
Entity Type:Individual
Prefix:
First Name:JESSECA
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 STACY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1439
Mailing Address - Country:US
Mailing Address - Phone:734-329-1859
Mailing Address - Fax:
Practice Address - Street 1:2688 PEACHCREST ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3323
Practice Address - Country:US
Practice Address - Phone:734-329-1859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703112763164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114014529Medicaid