Provider Demographics
NPI:1376147629
Name:MICHNIEWICZ, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MICHNIEWICZ
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 1:7011 QUAIL LAKES DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9390
Mailing Address - Country:US
Mailing Address - Phone:734-751-9387
Mailing Address - Fax:
Practice Address - Street 1:9666 OLDE US 20
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1710
Practice Address - Country:US
Practice Address - Phone:419-872-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist