Basic Information
| Provider Information | |||||||||
| NPI: | 1891166690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKI | ||||||||
| FirstName: | JENNA | ||||||||
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| Credential: | AT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 COUNTS COVE CT | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494242592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169942296 | ||||||||
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| Practice Location | |||||||||
| Address1: | 602 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494234918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163925141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2015 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 2601001590 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.