Provider Demographics
NPI:1750144069
Name:JEWELL, PENNIE
Entity type:Individual
Prefix:
First Name:PENNIE
Middle Name:
Last Name:JEWELL
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 1:110 E MILL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:MI
Mailing Address - Zip Code:49011-5110
Mailing Address - Country:US
Mailing Address - Phone:269-275-3559
Mailing Address - Fax:
Practice Address - Street 1:110 E MILL
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:MI
Practice Address - Zip Code:49011-5110
Practice Address - Country:US
Practice Address - Phone:269-275-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker