Provider Demographics
NPI:1639040413
Name:BERRY, JAE (RN)
Entity type:Individual
Prefix:MS
First Name:JAE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JAQETTA
Other - Middle Name:D
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:100 RIVERFRONT DR APT 1606
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4539
Mailing Address - Country:US
Mailing Address - Phone:313-444-3489
Mailing Address - Fax:586-408-6000
Practice Address - Street 1:100 RIVERFRONT DR APT 1606
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-4539
Practice Address - Country:US
Practice Address - Phone:313-444-3489
Practice Address - Fax:586-408-6000
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704403446202K00000X, 163WC0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No171M00000XOther Service ProvidersCase Manager/Care Coordinator