1710115258 NPI number — JAREN MARIE PICKENS GEBHARD PT

Table of content: JAREN MARIE PICKENS GEBHARD PT (NPI 1710115258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710115258 NPI number — JAREN MARIE PICKENS GEBHARD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEBHARD
Provider First Name:
JAREN
Provider Middle Name:
MARIE PICKENS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PICKENS
Provider Other First Name:
JAREN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710115258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7402 WESTSHIRE DR STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48917-8687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-853-6800
Provider Business Mailing Address Fax Number:
517-853-6801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13105 SCHAVEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEWITT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48820-9037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-853-6800
Provider Business Practice Location Address Fax Number:
517-853-6801
Provider Enumeration Date:
06/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501011698 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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