Healthcare Provider Details

I. General information

NPI: 1225716186
Provider Name (Legal Business Name): JENNIFER SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PAGE AVE
JACKSON MI
49201-2419
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1234
  • Fax:
Mailing address:
  • Phone: 313-876-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704354239
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704354239
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: