Provider Demographics
NPI:1770867657
Name:WERTH, JENNY LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LEE
Last Name:WERTH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD A201
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:1215 E. MICHIGAN AVE
Practice Address - Street 2:TRAUMA CENTER
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:517-364-3525
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1770867657Medicaid
MI0M61830036Medicare PIN