Basic Information
Provider Information | |||||||||
NPI: | 1255844452 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLBERG | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DILLARD | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 24 FRANK LLOYD WRIGHT DR STE J2000 | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481059484 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7347476766 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 990 W ANN ARBOR TRL STE 210 | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | MI | ||||||||
PostalCode: | 481706202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344554600 | ||||||||
FaxNumber: | 7344555637 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2017 | ||||||||
LastUpdateDate: | 12/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/11/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 4704290365 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208000000X | 20173296 | MI | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.