Provider Demographics
NPI:1497421358
Name:LETANG, JENNIE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:LETANG
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 1:2940 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7406
Mailing Address - Country:US
Mailing Address - Phone:734-572-5777
Mailing Address - Fax:
Practice Address - Street 1:2940 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-7406
Practice Address - Country:US
Practice Address - Phone:734-572-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704339310163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse