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General NPI Number Information
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NPI Number | 1992511828
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Entity Type | Individual
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Provider Name | JENEANE L HENDERSON-SHIELDS
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Gender | Female
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Dates
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Enumeration Date | 12/05/2024
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 4646 JOHN R ST
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City | DETROIT
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State | MI
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Zip | 48201-1916
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Country | US
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Telephone | 313-576-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 22065 HURON RIVER DR APT 215
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City | ROCKWOOD
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State | MI
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Zip | 48173-1177
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Country | US
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Telephone | 734-643-1349
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Fax |
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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 | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 4703097607
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License Number State | MI
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