Healthcare Provider Details

I. General information

NPI: 1215029277
Provider Name (Legal Business Name): ELIZABETH CHERITA JENKINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD INTERIM STAY UNIT
DEARBORN MI
48123-4089
US

IV. Provider business mailing address

4534 WEST OUTER DRIVE
DETROIT MI
48235-1210
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-5770
  • Fax: 313-982-5771
Mailing address:
  • Phone: 248-798-6753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704163024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: