Provider Demographics
NPI:1659322295
Name:JACINTO, LORELEE (PT)
Entity Type:Individual
Prefix:
First Name:LORELEE
Middle Name:
Last Name:JACINTO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5837 W VERNOR HWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-2159
Mailing Address - Country:US
Mailing Address - Phone:313-724-6336
Mailing Address - Fax:313-724-6379
Practice Address - Street 1:5837 W VERNOR HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2159
Practice Address - Country:US
Practice Address - Phone:313-724-6336
Practice Address - Fax:313-724-6379
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9438025OtherPHCS
MI5212346Medicaid
MI7536818OtherAETNA
MI205597714OtherPPOM
MI650H231040OtherBLUE CROSS BLUE SHIELD
062028OtherHAP
MI7536818OtherAETNA