Healthcare Provider Details

I. General information

NPI: 1003314519
Provider Name (Legal Business Name): SUZANNE KATHLEEN HARMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE
JACKSON MI
49201-1852
US

IV. Provider business mailing address

12018 SWAN VIEW DR
BROOKLYN MI
49230-8536
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1802
  • Fax:
Mailing address:
  • Phone: 517-414-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000112
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: