Healthcare Provider Details

I. General information

NPI: 1205541356
Provider Name (Legal Business Name): JESSICA MARIE KEOWN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28001 SCHOENHERR RD STE 628001
WARREN MI
48088-4396
US

IV. Provider business mailing address

28001 SCHOENHERR RD STE 628001
WARREN MI
48088-4396
US

V. Phone/Fax

Practice location:
  • Phone: 586-999-8330
  • Fax:
Mailing address:
  • Phone: 586-999-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5502008146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: