Provider Demographics
NPI:1255595591
Name:JAO, JENNIFER FARALAN (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FARALAN
Last Name:JAO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15545 LAKESIDE VILLAGE DR. APT 304
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:631-807-6716
Mailing Address - Fax:
Practice Address - Street 1:15855 NINETEEN MILE ROAD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-263-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017618207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine