Provider Demographics
NPI:1124013859
Name:PLATKUS, JENNIFER (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PLATKUS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:STE 406
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-557-9010
Mailing Address - Fax:248-557-3655
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:STE 406
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-557-9010
Practice Address - Fax:248-557-3655
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4579525Medicaid
MI5008602800OtherBLUE CROSS BLUE SHIELD
MI5008602800OtherBLUE CROSS BLUE SHIELD
MI4579525Medicaid
MIQ09582Medicare UPIN