Healthcare Provider Details

I. General information

NPI: 1770416521
Provider Name (Legal Business Name): JERRY E HARPOLE III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N INGALLS ST
ANN ARBOR MI
48109-2003
US

IV. Provider business mailing address

2911 W GRAND BLVD APT 6146
DETROIT MI
48202-2696
US

V. Phone/Fax

Practice location:
  • Phone: 505-793-5218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704409420
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: