Provider Demographics
NPI:1124659248
Name:STOCKWELL, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 W BLOOMINGDALE AVE STE C2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:447 S WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1763
Practice Address - Country:US
Practice Address - Phone:844-214-4446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4501008202176P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176P00000XOther Service ProvidersFuneral Director