Provider Demographics
NPI:1699136838
Name:JEX, TERESA ANNE (MS)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:ANNE
Last Name:JEX
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 N HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-1222
Mailing Address - Country:US
Mailing Address - Phone:810-679-0200
Mailing Address - Fax:810-679-0202
Practice Address - Street 1:2932 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8811
Practice Address - Country:US
Practice Address - Phone:810-966-9191
Practice Address - Fax:810-679-0202
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI13795639OtherCAQH
MI6803086827OtherSOCIAL SERVICE TECHNICIAN
21270OtherNCTRC