Healthcare Provider Details

I. General information

NPI: 1891166690
Provider Name (Legal Business Name): JENNA MAKI AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 MICHIGAN AVE
HOLLAND MI
49423-4918
US

IV. Provider business mailing address

16 COUNTS COVE CT
HOLLAND MI
49424-2592
US

V. Phone/Fax

Practice location:
  • Phone: 616-392-5141
  • Fax:
Mailing address:
  • Phone: 616-994-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2601001590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: