Provider Demographics
NPI:1669048138
Name:JURY, KATELYN ANNE (CPHT)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:ANNE
Last Name:JURY
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 VESSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1564
Mailing Address - Country:US
Mailing Address - Phone:517-604-0134
Mailing Address - Fax:
Practice Address - Street 1:1339 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1629
Practice Address - Country:US
Practice Address - Phone:517-647-4704
Practice Address - Fax:517-647-6896
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303033293183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician