Healthcare Provider Details

I. General information

NPI: 1912660689
Provider Name (Legal Business Name): JACQUELINE TIERNAN OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE WHITUS

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 E EISENHOWER PKWY
ANN ARBOR MI
48108-3231
US

IV. Provider business mailing address

PO BOX 6069
ANN ARBOR MI
48106-6069
US

V. Phone/Fax

Practice location:
  • Phone: 734-677-0070
  • Fax:
Mailing address:
  • Phone: 248-202-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201012677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: