Provider Demographics
NPI:1871951822
Name:BERRO, JINA
Entity type:Individual
Prefix:
First Name:JINA
Middle Name:
Last Name:BERRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20512 BROOKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20512 BROOKWOOD ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2768
Practice Address - Country:US
Practice Address - Phone:313-213-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2022-07-26
Deactivation Date:2020-01-08
Deactivation Code:
Reactivation Date:2022-07-19
Provider Licenses
StateLicense IDTaxonomies
MI7501004963225700000X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist