Healthcare Provider Details

I. General information

NPI: 1114947959
Provider Name (Legal Business Name): JENNIFER L RISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13355 E 10 MILE RD SUITE 229
WARREN MI
48089-2048
US

IV. Provider business mailing address

37399 GARFIELD RD STE 203
CLINTON TWP MI
48036-3672
US

V. Phone/Fax

Practice location:
  • Phone: 586-758-6263
  • Fax: 586-758-7725
Mailing address:
  • Phone: 586-228-2911
  • Fax: 586-228-2901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101011870
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: