Healthcare Provider Details

I. General information

NPI: 1881519460
Provider Name (Legal Business Name): JESSICA LYNN CANTRELL MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3957 LAWLEY AVE
WATERFORD MI
48328-4053
US

IV. Provider business mailing address

3957 LAWLEY AVE
WATERFORD MI
48328-4053
US

V. Phone/Fax

Practice location:
  • Phone: 586-350-4894
  • Fax:
Mailing address:
  • Phone: 586-350-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: