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General NPI Number Information
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NPI Number | 1265974752
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Entity Type | Individual
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Provider Name | JENNIFER BOGEN
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Gender | Female
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Dates
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Enumeration Date | 11/15/2016
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Last Update Date | 11/15/2016
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Provider Practice Location Address
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Address Line | 106 S STEWART AVE
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City | FREMONT
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State | MI
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Zip | 49412-1624
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Country | US
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Telephone | 231-924-3456
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Fax | 231-924-3443
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Provider Business Mailing Address
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Address Line | 8054 MEINERT PARK RD
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City | MONTAGUE
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State | MI
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Zip | 49437-8708
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Country | US
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Telephone | 231-924-3456
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Fax | 231-924-3443
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 7501008414
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License Number State | MI
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