Provider Demographics
NPI:1619746146
Name:JERNAGIN, TACARRA
Entity Type:Individual
Prefix:
First Name:TACARRA
Middle Name:
Last Name:JERNAGIN
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 1:2315 STEEPLECHASE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-0026
Mailing Address - Country:US
Mailing Address - Phone:124-867-8797
Mailing Address - Fax:
Practice Address - Street 1:21509 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1512
Practice Address - Country:US
Practice Address - Phone:734-460-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
MI4704340544364S00000X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No251E00000XAgenciesHome Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist