Provider Demographics
NPI:1679894117
Name:SIMONS, JENNIFER L (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SIMONS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1999
Mailing Address - Country:US
Mailing Address - Phone:231-547-4024
Mailing Address - Fax:231-547-8088
Practice Address - Street 1:14700 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1999
Practice Address - Country:US
Practice Address - Phone:231-547-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704246607367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679894117Medicaid
0B86029 026Medicare PIN