Healthcare Provider Details

I. General information

NPI: 1669851796
Provider Name (Legal Business Name): JONATHAN DOELLNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 KERCHEVAL AVE
GROSSE POINTE FARMS MI
48236-3629
US

IV. Provider business mailing address

550 BALDWIN ST
JENISON MI
49428-9753
US

V. Phone/Fax

Practice location:
  • Phone: 313-693-0214
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5302040947
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: