Provider Demographics
NPI:1801833975
Name:KLOCK, JENNIFER L (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:810-249-4037
Practice Address - Street 1:1510 S STATE RD
Practice Address - Street 2:STE D
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1965
Practice Address - Country:US
Practice Address - Phone:810-652-3600
Practice Address - Fax:810-652-3603
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101015640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM23560173Medicare PIN