Provider Demographics
NPI:1457497471
Name:GILES, JENNY (PAC)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:GILES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:GILES-VOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1206 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3555
Mailing Address - Country:US
Mailing Address - Phone:810-985-6778
Mailing Address - Fax:
Practice Address - Street 1:4071 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3801
Practice Address - Country:US
Practice Address - Phone:810-824-4222
Practice Address - Fax:810-824-4220
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1457497471Medicaid
MI1457497471Medicaid