Provider Demographics
NPI:1164785028
Name:HAVENS, JESSICA JEAN (ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEAN
Last Name:HAVENS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JEAN
Other - Last Name:POSSEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10040 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9486
Mailing Address - Country:US
Mailing Address - Phone:269-838-5089
Mailing Address - Fax:
Practice Address - Street 1:10040 BAKER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9486
Practice Address - Country:US
Practice Address - Phone:269-838-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-16
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010006432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer