Provider Demographics
NPI:1558852871
Name:DBAIBOU, JANA (MD)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:DBAIBOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE ST.
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-745-7888
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE ST.
Practice Address - Street 2:SUITE 2E
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2019-03-27
Deactivation Date:2019-01-22
Deactivation Code:
Reactivation Date:2019-03-27
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301115070390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program