Provider Demographics
NPI:1104568740
Name:SCOTT, JENNA DANIELLE (CEP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:DANIELLE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:CEP
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:DANIELLE
Other - Last Name:MALLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CEP
Mailing Address - Street 1:305 E NEWARK RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-9408
Mailing Address - Country:US
Mailing Address - Phone:248-904-5754
Mailing Address - Fax:
Practice Address - Street 1:305 E NEWARK RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-9408
Practice Address - Country:US
Practice Address - Phone:248-904-5754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist