Provider Demographics
NPI:1871912550
Name:MANCUSO, JENNIFER BRESCOLL (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BRESCOLL
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUSAN
Other - Last Name:BRESCOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:1ST FLOOR TAUBMAN CENTER RECP 'B'
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5314
Practice Address - Country:US
Practice Address - Phone:734-936-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105772207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology