Healthcare Provider Details

I. General information

NPI: 1780173476
Provider Name (Legal Business Name): JUSTINE RAE FERRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E MICHIGAN AVE
JACKSON MI
49201-1498
US

IV. Provider business mailing address

9880 SOMERSET RD
CEMENT CITY MI
49233-9031
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501018514
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: