Provider Demographics
NPI:1700033859
Name:NORTHWESTERN MICHIGAN COLLEGE
Entity Type:Organization
Organization Name:NORTHWESTERN MICHIGAN COLLEGE
Other - Org Name:NORTHWESTERN MICHIGAN COLLEGE STUDENT HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:231-995-1256
Mailing Address - Street 1:1701 E FRONT ST
Mailing Address - Street 2:L.B. 106
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3016
Mailing Address - Country:US
Mailing Address - Phone:231-995-1255
Mailing Address - Fax:231-995-1923
Practice Address - Street 1:1701 E FRONT ST
Practice Address - Street 2:L.B. 106
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3016
Practice Address - Country:US
Practice Address - Phone:231-995-1255
Practice Address - Fax:231-995-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704147470261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health