Healthcare Provider Details

I. General information

NPI: 1669150223
Provider Name (Legal Business Name): JENNIFER LYNN JENNINGS I LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R
DETROIT MI
48201
US

IV. Provider business mailing address

4646 JOHN R ST
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-3966
  • Fax:
Mailing address:
  • Phone: 734-626-3894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number4703083772
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703083772
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: