Provider Demographics
NPI:1174014674
Name:STEFANI, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STEFANI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14606 MICHIGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1067
Mailing Address - Country:US
Mailing Address - Phone:313-382-3108
Mailing Address - Fax:
Practice Address - Street 1:22650 SIBLEY RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:MI
Practice Address - Zip Code:48193-8231
Practice Address - Country:US
Practice Address - Phone:734-783-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist