Provider Demographics
NPI:1730731829
Name:SAMUELSON, JESSICA RENEE (DNP FNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:DNP FNP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RENEE
Other - Last Name:THICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP FNP-BC
Mailing Address - Street 1:1639 FARNSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-8711
Mailing Address - Country:US
Mailing Address - Phone:810-358-2902
Mailing Address - Fax:
Practice Address - Street 1:3400 FLECKENSTEIN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3042
Practice Address - Country:US
Practice Address - Phone:810-358-2902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily