Provider Demographics
NPI:1548687312
Name:LOPICCOLO, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOPICCOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8545 COMMON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-6772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8545 COMMON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-6772
Practice Address - Country:US
Practice Address - Phone:586-751-0732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704303547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily