Provider Demographics
NPI:1154108561
Name:VANDECAR, JENNIFER A (RE)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:A
Last Name:VANDECAR
Suffix:
Gender:F
Credentials:RE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 PACKARD ST STE 270
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2276
Mailing Address - Country:US
Mailing Address - Phone:734-971-8801
Mailing Address - Fax:734-971-7754
Practice Address - Street 1:3830 PACKARD ST STE 270
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2276
Practice Address - Country:US
Practice Address - Phone:734-971-8801
Practice Address - Fax:734-971-7754
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2704057120174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist