Provider Demographics
NPI:1902817935
Name:JANKE, KRISTIE LYNN (OTR)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:LYNN
Last Name:JANKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3847 PINE GROVE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4265
Mailing Address - Country:US
Mailing Address - Phone:810-985-4009
Mailing Address - Fax:810-984-8111
Practice Address - Street 1:3847 PINE GROVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4265
Practice Address - Country:US
Practice Address - Phone:810-985-4009
Practice Address - Fax:810-984-8111
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004622225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN96150008Medicare ID - Type Unspecified