Provider Demographics
NPI:1972241982
Name:DAVIS, JENNIFER KAY
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:DAVIS
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 1:2395 S WISE RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9413
Mailing Address - Country:US
Mailing Address - Phone:231-287-8442
Mailing Address - Fax:
Practice Address - Street 1:2395 S WISE RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9413
Practice Address - Country:US
Practice Address - Phone:231-287-8442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician