Provider Demographics
NPI:1053146498
Name:JESSE, VANESSA J (CIBD FSID)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:J
Last Name:JESSE
Suffix:
Gender:F
Credentials:CIBD FSID
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N15285 EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:MI
Mailing Address - Zip Code:49896-9622
Mailing Address - Country:US
Mailing Address - Phone:906-250-6429
Mailing Address - Fax:
Practice Address - Street 1:N15285 EAGLE RD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:MI
Practice Address - Zip Code:49896-9622
Practice Address - Country:US
Practice Address - Phone:906-250-6429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1053146498Medicaid
MI229993OtherUPHP