Healthcare Provider Details

I. General information

NPI: 1740655901
Provider Name (Legal Business Name): MRS. JEAN TASHINA TANIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2944 FULLER AVE NE SUITE 301
GRAND RAPIDS MI
49505-3784
US

IV. Provider business mailing address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

V. Phone/Fax

Practice location:
  • Phone: 616-284-5871
  • Fax: 616-774-1001
Mailing address:
  • Phone: 734-467-7600
  • Fax: 734-467-7636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: