Healthcare Provider Details

I. General information

NPI: 1407904436
Provider Name (Legal Business Name): JENNIFER ANN ANDREW I ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 S. SRAITS HWY.
INDIAN RIVER MI
49749
US

IV. Provider business mailing address

6506 CHIPPEWA TR. PO BOX 1007
INDIAN RIVER MI
49749
US

V. Phone/Fax

Practice location:
  • Phone: 231-238-4880
  • Fax: 231-238-8777
Mailing address:
  • Phone: 231-238-9231
  • Fax: 231-238-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: