Provider Demographics
NPI:1891197059
Name:RATLIFF-MOSS, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:RATLIFF-MOSS
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 1:4008 CALGARY CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2798
Mailing Address - Country:US
Mailing Address - Phone:734-905-6649
Mailing Address - Fax:734-369-3369
Practice Address - Street 1:5340 PLYMOUTH RD
Practice Address - Street 2:STE 208
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9341
Practice Address - Country:US
Practice Address - Phone:734-905-6649
Practice Address - Fax:734-369-3369
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010621901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI964328OtherBLUE CROSS BLUE SHEILD MICHIGAN
MIMI 10375Medicare PIN