Healthcare Provider Details

I. General information

NPI: 1437981909
Provider Name (Legal Business Name): JENNIFER RAYMO CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ROOT

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 W MAIN ST
FREMONT MI
49412-1416
US

IV. Provider business mailing address

2779 W 24TH ST
FREMONT MI
49412-9720
US

V. Phone/Fax

Practice location:
  • Phone: 843-323-2061
  • Fax:
Mailing address:
  • Phone: 843-323-2061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303039537
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: