Provider Demographics
NPI:1194215657
Name:WONSOWICZ, JENNA (DO)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WONSOWICZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29656 NEWPORT DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-8503
Mailing Address - Country:US
Mailing Address - Phone:586-201-6513
Mailing Address - Fax:
Practice Address - Street 1:27351 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3487
Practice Address - Country:US
Practice Address - Phone:248-967-7661
Practice Address - Fax:248-967-7876
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025779207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program