Provider Demographics
NPI:1700418712
Name:WELLNITZ, JACOB SCOTT (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SCOTT
Last Name:WELLNITZ
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2890 BURTCH RD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9416
Mailing Address - Country:US
Mailing Address - Phone:906-430-7448
Mailing Address - Fax:
Practice Address - Street 1:500 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1822
Practice Address - Country:US
Practice Address - Phone:906-635-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily