Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W UNIVERSITY DR STE A-2
ROCHESTER MI
48307-1817
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-266-0920
  • Fax:
Mailing address:
  • Phone: 810-357-5968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704387820
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: