Provider Demographics
NPI:1063470490
Name:MCCANN-BAUER, JENNIFER M (PT, MSPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MCCANN-BAUER
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MSPT
Mailing Address - Street 1:18000 COVE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1299
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:616-847-1290
Practice Address - Street 1:18000 COVE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1299
Practice Address - Country:US
Practice Address - Phone:616-847-1280
Practice Address - Fax:616-847-1290
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM98960012Medicare ID - Type Unspecified