Provider Demographics
NPI:1588245799
Name:PONTELLO, JESSICA (NP)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:PONTELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25631 LITTLE MACK AVE STE 205
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2108
Practice Address - Country:US
Practice Address - Phone:586-443-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308762363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology