Basic Information
| Provider Information | |||||||||
| NPI: | 1528347622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEJA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEVENS | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTOINE - UHC 5D - MAILBOX #226 | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454405 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF MI | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454405 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2011 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301099138 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 4301099138 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.