Provider Demographics
NPI:1437418589
Name:RUPLE, JENNA TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:TAYLOR
Last Name:RUPLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 HEALTH PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8242
Mailing Address - Country:US
Mailing Address - Phone:269-657-2550
Mailing Address - Fax:269-657-2285
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-657-2550
Practice Address - Fax:269-657-2285
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11016450A207Q00000X
IN01075489A207Q00000X
MI4301108074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000948449OtherBCBS E BLAIR WARNER
IN201112790Medicaid