Provider Demographics
NPI:1124472238
Name:CALLAN, JADE (MS, ATC)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:CALLAN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W SHIAWASSEE AVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2097
Mailing Address - Country:US
Mailing Address - Phone:616-405-3981
Mailing Address - Fax:
Practice Address - Street 1:408 W SHIAWASSEE AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2097
Practice Address - Country:US
Practice Address - Phone:616-405-3981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010013042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer