Healthcare Provider Details

I. General information

NPI: 1407386329
Provider Name (Legal Business Name): AMBRIA FAITH JUMP DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 S CEDAR ST STE 205
LANSING MI
48911-3800
US

IV. Provider business mailing address

PO BOX 30161
LANSING MI
48909-7661
US

V. Phone/Fax

Practice location:
  • Phone: 517-887-4305
  • Fax:
Mailing address:
  • Phone: 517-887-4305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101023398
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: