Provider Demographics
NPI:1316942725
Name:LENNOX, JACK D (DO)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:LENNOX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:28100 GRAND RIVER AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5969
Mailing Address - Country:US
Mailing Address - Phone:248-474-5575
Mailing Address - Fax:248-474-4679
Practice Address - Street 1:28100 GRAND RIVER AVE
Practice Address - Street 2:STE 209
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5969
Practice Address - Country:US
Practice Address - Phone:248-474-5575
Practice Address - Fax:248-474-4679
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIJL008625207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1928248Medicaid
E26106Medicare UPIN
M38130005Medicare ID - Type Unspecified