Healthcare Provider Details

I. General information

NPI: 1609428960
Provider Name (Legal Business Name): JENNIFER GUGLIELMI RSST, QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

IV. Provider business mailing address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

V. Phone/Fax

Practice location:
  • Phone: 734-467-7600
  • Fax:
Mailing address:
  • Phone: 734-467-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6803085528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: