Healthcare Provider Details

I. General information

NPI: 1134601586
Provider Name (Legal Business Name): JENNIFER MODINA ROQUE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2018
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS
DETROIT MI
48236
US

IV. Provider business mailing address

34841 FONTANA DRIVE
STERLING HEIGHTS MI
48312
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-4370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704231669
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704231669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: