Provider Demographics
NPI:1083099402
Name:MARTZ, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MARTZ
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 1:6300 N HAGGERTY RD
Mailing Address - Street 2:SUITE NUMBER 210
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6300 N HAGGERTY RD
Practice Address - Street 2:SUITE NUMBER 210
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3568
Practice Address - Country:US
Practice Address - Phone:734-641-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily