Provider Demographics
NPI:1679271647
Name:TOBIAS, JESSICA LYNN (CPSS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:TOBIAS
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WOOD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KINCHELOE
Mailing Address - State:MI
Mailing Address - Zip Code:49788-1128
Mailing Address - Country:US
Mailing Address - Phone:906-203-7790
Mailing Address - Fax:
Practice Address - Street 1:248 FERRY LN
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1828
Practice Address - Country:US
Practice Address - Phone:906-984-2080
Practice Address - Fax:906-984-2109
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI175T00000XMedicaid