Provider Demographics
NPI:1780173476
Name:FERRIS, JUSTINE RAE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:RAE
Last Name:FERRIS
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 1:9880 SOMERSET RD
Mailing Address - Street 2:
Mailing Address - City:CEMENT CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49233-9031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1498
Practice Address - Country:US
Practice Address - Phone:517-205-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501018514OtherPHYSICAL THERAPIST LICENSE