Healthcare Provider Details

I. General information

NPI: 1619746146
Provider Name (Legal Business Name): TACARRA JERNAGIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21509 FENKELL ST
DETROIT MI
48223-1512
US

IV. Provider business mailing address

2315 STEEPLECHASE RD
CANTON MI
48188-0026
US

V. Phone/Fax

Practice location:
  • Phone: 734-460-5100
  • Fax:
Mailing address:
  • Phone: 124-867-8797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number4704340544
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704340544
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: