Provider Demographics
NPI:1336640358
Name:ANGEL, JEAN THOMSON (PT)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:THOMSON
Last Name:ANGEL
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 1:300 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1316
Mailing Address - Country:US
Mailing Address - Phone:313-587-2520
Mailing Address - Fax:
Practice Address - Street 1:33000 ANNAPOLIS ST STE 210
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2920
Practice Address - Country:US
Practice Address - Phone:734-467-4134
Practice Address - Fax:734-467-4699
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-25
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty