Provider Demographics
NPI:1912660689
Name:TIERNAN, JACQUELINE (OTRL)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TIERNAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:WHITUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-6069
Mailing Address - Country:US
Mailing Address - Phone:248-202-0965
Mailing Address - Fax:
Practice Address - Street 1:3200 E EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3231
Practice Address - Country:US
Practice Address - Phone:734-677-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201012677225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist