Healthcare Provider Details

I. General information

NPI: 1144926551
Provider Name (Legal Business Name): JENNIFER RENO-FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER RENO

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36880 WOODWARD AVE STE 102
BLOOMFIELD HILLS MI
48304-0920
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 248-480-7440
  • Fax: 248-480-7441
Mailing address:
  • Phone: 586-350-2644
  • Fax: 586-541-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501302288
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: