Provider Demographics
NPI:1275412355
Name:DAVENPORT, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 HILL DR APT 202
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-4810
Mailing Address - Country:US
Mailing Address - Phone:810-357-5968
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-985-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704387820163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health