Provider Demographics
NPI:1457967507
Name:HARRIS, JENNA (PT, DPT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22731 NEWMAN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2023
Mailing Address - Country:US
Mailing Address - Phone:313-982-0200
Mailing Address - Fax:313-982-0500
Practice Address - Street 1:22731 NEWMAN ST STE 200
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2023
Practice Address - Country:US
Practice Address - Phone:313-982-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist