Basic Information
| Provider Information | |||||||||
| NPI: | 1942432877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLUM | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | AMBER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT,ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOWARD | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | AMBER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT,ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9368 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344163900 | ||||||||
| FaxNumber: | 7344163903 | ||||||||
| Practice Location | |||||||||
| Address1: | 9368 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344163900 | ||||||||
| FaxNumber: | 7344163903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2009 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501014667 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.