Provider Demographics
NPI:1689820169
Name:NOBERT, JENNIFER LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:NOBERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:STOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PC-C
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2332 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1955
Practice Address - Country:US
Practice Address - Phone:616-391-9536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant