1912026758 NPI number — MR. MARY ALICE JENNINGS SW, CAC1

Table of content: MR. MARY ALICE JENNINGS SW, CAC1 (NPI 1912026758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912026758 NPI number — MR. MARY ALICE JENNINGS SW, CAC1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENNINGS
Provider First Name:
MARY ALICE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SW, CAC1
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENNINGS
Provider Other First Name:
MARTY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
S.W. CAC1
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1912026758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
775 MOORLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE POINTE WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-886-2724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13336 E. WARREN AVE
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:
48236-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-822-6940
Provider Business Practice Location Address Fax Number:
313-822-6946
Provider Enumeration Date:
03/29/2007

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 , with the licence number:  1-00266 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 104100000X , with the licence number: 6802057046 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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