Basic Information
| Provider Information | |||||||||
| NPI: | 1497164586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAWSKI | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 64541 VAN DYKE RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480952570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869351100 | ||||||||
| FaxNumber: | 5869351101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2014 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501016794 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.