Provider Demographics
NPI:1598196677
Name:JAGU, UMAKANTH REDDY
Entity Type:Individual
Prefix:
First Name:UMAKANTH
Middle Name:REDDY
Last Name:JAGU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37845 DALE DR
Mailing Address - Street 2:# 302
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7526
Mailing Address - Country:US
Mailing Address - Phone:734-693-5780
Mailing Address - Fax:
Practice Address - Street 1:22950 NORTHINE ROAD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:734-287-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501014042OtherPHYSICALTHERAPY LICENSE