Provider Demographics
NPI:1902356272
Name:DUDEESH, JISHA (NP)
Entity Type:Individual
Prefix:
First Name:JISHA
Middle Name:
Last Name:DUDEESH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22151 MOROSS RD
Mailing Address - Street 2:PROFESSIONAL BUILDING ONE
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2167
Mailing Address - Country:US
Mailing Address - Phone:313-343-7107
Mailing Address - Fax:
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:PROFESSIONAL BUILDING ONE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704256647363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner