Healthcare Provider Details

I. General information

NPI: 1518757764
Provider Name (Legal Business Name): JEREMY LOCKENOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2025
Last Update Date: 05/10/2025
Certification Date: 05/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

6828 OSAGE AVE
ALLEN PARK MI
48101-2374
US

V. Phone/Fax

Practice location:
  • Phone: 313-912-1094
  • Fax:
Mailing address:
  • Phone: 313-912-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704376010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: