Provider Demographics
NPI:1437105442
Name:GRUTZIK, JENNIFER RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:GRUTZIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RENEE
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2908 MALL RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1641
Mailing Address - Country:US
Mailing Address - Phone:256-767-2702
Mailing Address - Fax:256-718-6047
Practice Address - Street 1:2908 MALL RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1641
Practice Address - Country:US
Practice Address - Phone:256-767-2702
Practice Address - Fax:256-718-6047
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.459363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA.459OtherMEDICAL LICENSE
AL107569Medicaid