Provider Demographics
NPI:1467938084
Name:FUSSELL, JENNA CORINNE COON (MD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:CORINNE COON
Last Name:FUSSELL
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 1:221 MICHIGN ST NE STE 402
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2538
Mailing Address - Country:US
Mailing Address - Phone:616-391-1405
Mailing Address - Fax:616-391-8611
Practice Address - Street 1:1700 TREE LN STE 320
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6747
Practice Address - Country:US
Practice Address - Phone:770-972-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351035412208600000X
GA96435208600000X
MI4301115839208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery