Provider Demographics
NPI:1578917381
Name:NIMTZ, JENNIFER SUE (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:NIMTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24146 MEADOWBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3008
Mailing Address - Country:US
Mailing Address - Phone:989-980-7652
Mailing Address - Fax:
Practice Address - Street 1:3031 W GRAND BLVD
Practice Address - Street 2:SUITE 450
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3046
Practice Address - Country:US
Practice Address - Phone:313-346-5235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022645208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics