Provider Demographics
NPI:1164072385
Name:DEVENNEY, MARY JACQUELINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JACQUELINE
Last Name:DEVENNEY
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 1:19591 PARTELLO RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9349
Mailing Address - Country:US
Mailing Address - Phone:269-986-1985
Mailing Address - Fax:
Practice Address - Street 1:2121 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3658
Practice Address - Country:US
Practice Address - Phone:517-787-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202005034224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant