Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501006617 | MI |
NPI | 1003029976 |
---|---|
Provider Name | Penelope Jones |
First Address | Rochester Hills, MI 48307-3326 |
Second Address | Rochester, MI 48307-1871 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2007 |
Last Update Date | 04/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5501006617 | LICENSE NUMBER (01) | MI |