Provider Demographics
NPI:1740293869
Name:ADAMS, JEANENE (CRNA)
Entity type:Individual
Prefix:
First Name:JEANENE
Middle Name:
Last Name:ADAMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 203401
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:952-442-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704142666367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJA142666OtherBLUE CROSS OF MI
MIN24360060Medicare ID - Type Unspecified