Provider Demographics
NPI:1265522999
Name:JENNETT, MARY K (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:JENNETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3519 E POINT DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:MI
Mailing Address - Zip Code:48612-8742
Mailing Address - Country:US
Mailing Address - Phone:989-435-8890
Mailing Address - Fax:
Practice Address - Street 1:4005 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-0001
Practice Address - Country:US
Practice Address - Phone:989-839-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704159661367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3294932Medicaid
MIMJ159661OtherBLUE SHIELD