Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 6301014633 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301014633 | MI |
NPI | 1003253253 |
---|---|
Provider Name | Michelle Theresa Jesse |
First Address | Royal Oak, MI 48073-1624 |
Second Address | Detroit, MI 48202-2608 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2013 |
Last Update Date | 12/03/2021 |