Provider Demographics
NPI:1720535552
Name:DESTEFANO, JENNIFER (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BEZRUTCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2879 ROUNDTREE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2331
Mailing Address - Country:US
Mailing Address - Phone:586-604-0465
Mailing Address - Fax:
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:313-473-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282745363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily