Healthcare Provider Details

I. General information

NPI: 1891429205
Provider Name (Legal Business Name): JACQUELINE RENEE HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKLANE BLVD STE 200E
DEARBORN MI
48126-2400
US

IV. Provider business mailing address

27085 GRATIOT AVE
ROSEVILLE MI
48066-2984
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-2606
  • Fax:
Mailing address:
  • Phone: 586-204-5560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201002513
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: