Provider Demographics
NPI:1992273197
Name:POWERS, JEANNINE
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:POWERS
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 1:3536 QUEBEC TRL
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-1409
Mailing Address - Country:US
Mailing Address - Phone:616-890-1604
Mailing Address - Fax:
Practice Address - Street 1:3536 QUEBEC TRL
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1409
Practice Address - Country:US
Practice Address - Phone:616-890-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109884164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid