Provider Demographics
NPI:1457183410
Name:FASICK, JESSE LYNN
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:LYNN
Last Name:FASICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14693 CINDER RD
Mailing Address - Street 2:
Mailing Address - City:BEULAH
Mailing Address - State:MI
Mailing Address - Zip Code:49617-9367
Mailing Address - Country:US
Mailing Address - Phone:231-633-6133
Mailing Address - Fax:
Practice Address - Street 1:105 HALL ST UNIT A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2288
Practice Address - Country:US
Practice Address - Phone:231-922-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker