Provider Demographics
NPI:1568005569
Name:DATZKO, JENNIFER LYNN (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DATZKO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 639295 DEPT 93303
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:1484 STRAITS DR STE 5
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-8718
Practice Address - Country:US
Practice Address - Phone:989-667-8740
Practice Address - Fax:989-667-8745
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704233200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner