Provider Demographics
NPI:1568726792
Name:GREENBERG, JENNA BURK (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:BURK
Last Name:GREENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNA
Other - Middle Name:B
Other - Last Name:WISSOCKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:14700 E OLD US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1185
Practice Address - Country:US
Practice Address - Phone:734-475-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101274207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program