Provider Demographics
NPI:1730163932
Name:JUDY, JESSICA AC (NP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AC
Last Name:JUDY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0220
Mailing Address - Country:US
Mailing Address - Phone:906-225-4821
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:800 EAST BLVD
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4436
Practice Address - Country:US
Practice Address - Phone:906-774-4000
Practice Address - Fax:906-774-0088
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704220408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008750240OtherBLUE CROSS BLUE SHIELD MI
MI4705237Medicaid
MI4705237Medicaid
MI233885Medicare Oscar/Certification
MIQ40928Medicare UPIN