1093095093 NPI number — MS. JESSIKA BETH RENUSCH MA, CADC

Table of content: MS. JESSIKA BETH RENUSCH MA, CADC (NPI 1093095093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093095093 NPI number — MS. JESSIKA BETH RENUSCH MA, CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENUSCH
Provider First Name:
JESSIKA
Provider Middle Name:
BETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RENUSCH
Provider Other First Name:
JESSICA
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093095093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
751 E GRAND BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-922-2222
Provider Business Mailing Address Fax Number:
866-287-5710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 E GRAND BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-922-2222
Provider Business Practice Location Address Fax Number:
866-287-5710
Provider Enumeration Date:
08/22/2011

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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