Provider Demographics
NPI:1679155303
Name:EDWARDS, JESSICA (RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50955 BREDENBURY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1387
Mailing Address - Country:US
Mailing Address - Phone:586-907-3932
Mailing Address - Fax:
Practice Address - Street 1:46977 ROMEO PLANK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-3509
Practice Address - Country:US
Practice Address - Phone:586-286-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704312345163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy