Provider Demographics
NPI:1265498125
Name:J C CLINIC
Entity Type:Organization
Organization Name:J C CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-794-0112
Mailing Address - Street 1:2035 HOGBACK RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9732
Mailing Address - Country:US
Mailing Address - Phone:734-794-0112
Mailing Address - Fax:734-794-0112
Practice Address - Street 1:2035 HOGBACK RD
Practice Address - Street 2:SUITE 209
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9732
Practice Address - Country:US
Practice Address - Phone:734-794-0112
Practice Address - Fax:734-794-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010793832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4505719Medicaid
H79731OtherHAP HMO
136855OtherCARE CHOICES
H79731OtherHAP HMO
OP24130Medicare ID - Type Unspecified