Provider Demographics
NPI:1902397862
Name:DEBLOUW, JENNIFER LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:DEBLOUW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26551 24 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-1515
Mailing Address - Country:US
Mailing Address - Phone:810-531-0142
Mailing Address - Fax:
Practice Address - Street 1:1980 FRED W MOORE HWY
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-4701
Practice Address - Country:US
Practice Address - Phone:810-329-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI226321223G0001X
MI2901022632122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice