Provider Demographics
NPI:1386116234
Name:GENOVESE, JAYNE MARIE
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:MARIE
Last Name:GENOVESE
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 1:645 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9373
Mailing Address - Country:US
Mailing Address - Phone:989-362-5834
Mailing Address - Fax:
Practice Address - Street 1:3007 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4555
Practice Address - Country:US
Practice Address - Phone:989-356-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist