Healthcare Provider Details

I. General information

NPI: 1215479407
Provider Name (Legal Business Name): MRS. JENNIFER TANK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2016
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 TERI DEE UNIT C
CADILLAC MI
49601-8318
US

IV. Provider business mailing address

9719 S BRIAR AVE
BALDWIN MI
49304-7761
US

V. Phone/Fax

Practice location:
  • Phone: 231-268-0360
  • Fax:
Mailing address:
  • Phone: 734-277-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: