Provider Demographics
NPI:1427077452
Name:OSEI YEBOAH, JESSICA (PAC)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:OSEI YEBOAH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098
Mailing Address - Country:US
Mailing Address - Phone:269-463-3600
Mailing Address - Fax:269-463-8206
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9225
Practice Address - Country:US
Practice Address - Phone:269-463-3600
Practice Address - Fax:269-463-8206
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1427077452Medicaid