Provider Demographics
NPI:1114947959
Name:RISE, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:RISE
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 1:37399 GARFIELD RD
Mailing Address - Street 2:STE 203
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3672
Mailing Address - Country:US
Mailing Address - Phone:586-228-2911
Mailing Address - Fax:586-228-2901
Practice Address - Street 1:13355 E 10 MILE RD
Practice Address - Street 2:SUITE 229
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2048
Practice Address - Country:US
Practice Address - Phone:586-758-6263
Practice Address - Fax:586-758-7725
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3263097Medicaid
OM02290005Medicare ID - Type Unspecified
MI3263097Medicaid