Healthcare Provider Details

I. General information

NPI: 1275412355
Provider Name (Legal Business Name): JACOB DAVENPORT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

4036 HILL DR APT 202
SHELBY TOWNSHIP MI
48317-4810
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-8900
  • Fax:
Mailing address:
  • Phone: 810-357-5968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704387820
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: