MEDICARE: JENNIFER LYNN LEGG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501007170	MI

General Provider Information

NPI Number	:	1750866059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LYNN LEGG

Provider Business Mailing Address
First Line	:	116 LAKESHORE DR
Second Line	:
City	:	CLARKSTON
State	:	MI
Zip	:	48348-1480
Country	:	US
Telephone Number	:	248-561-4254
Fax Number	:

Provider Business Practice Location Address
First Line	:	2251 N SQUIRREL RD STE 320
Second Line	:
City	:	AUBURN HILLS
State	:	MI
Zip	:	48326-4608
Country	:	US
Telephone Number	:	248-656-6757
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	10/02/2018

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