Provider Demographics
NPI:1265974752
Name:BOGEN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOGEN
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 1:8054 MEINERT PARK RD
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437-8708
Mailing Address - Country:US
Mailing Address - Phone:231-924-3456
Mailing Address - Fax:231-924-3443
Practice Address - Street 1:106 S STEWART AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1624
Practice Address - Country:US
Practice Address - Phone:231-924-3456
Practice Address - Fax:231-924-3443
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008414225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist