Provider Demographics
NPI:1598141822
Name:AGRUSA, JENNIFER (DNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AGRUSA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43455 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1951
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:
Practice Address - Street 1:43455 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1951
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:586-726-8365
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278593363LA2200X
MI1639105695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598141822Medicaid