Provider Demographics
NPI:1235339334
Name:FOESS-HALAAS, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:FOESS-HALAAS
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:
Practice Address - Street 1:201 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2605
Practice Address - Country:US
Practice Address - Phone:734-697-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102262802Medicaid
MI0H249999OtherBCBSM
MI0H249999OtherBCBSM