MEDICARE: MRS. JENNA SOULLIERE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	7401001159	MI

General Provider Information

NPI Number	:	1396294054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNA SOULLIERE

Provider Business Mailing Address
First Line	:	1525 RIDGEWOOD DR
Second Line	:
City	:	MIDLAND
State	:	MI
Zip	:	48642-6425
Country	:	US
Telephone Number	:	989-205-0168
Fax Number	:

Provider Business Practice Location Address
First Line	:	3727 WILDER RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2367
Country	:	US
Telephone Number	:	989-860-1425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	04/17/2023

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