Basic Information
| Provider Information | |||||||||
| NPI: | 1669979670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTIN | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6004 RELIABLE PARKWAY LOCKBOX CHI 866004 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342632400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2018 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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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 | 163W00000X | RN2293762 | MA | N | Nursing Service Providers | Registered Nurse | 367500000X | 4704308220 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1669979670 | 05 | MI | MEDICAID |