Basic Information
| Provider Information | |||||||||
| NPI: | 1548269897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | TESSY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27200 LAHSER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482089215 | ||||||||
| FaxNumber: | 2482089217 | ||||||||
| Practice Location | |||||||||
| Address1: | 27200 LAHSER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482089215 | ||||||||
| FaxNumber: | 2482089217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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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 | 2084N0400X | 4301058568 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 4301058568 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 5535883 | 01 | MI | FIRST HEALTH | OTHER | 1306303571 | 01 | MI | BCBS | OTHER | 4639614 | 05 | MI | MEDICAID | P111695 | 01 | MI | BLUECARE NETWORK | OTHER | 7794125 | 01 | MI | AETNA | OTHER | G35452 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER |