Provider Demographics
NPI:1821078411
Name:OSSTIFIN-CZERNIEJEWSKI, JENNIFER L (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:OSSTIFIN-CZERNIEJEWSKI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23255 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-5240
Mailing Address - Country:US
Mailing Address - Phone:734-287-3000
Mailing Address - Fax:734-287-3113
Practice Address - Street 1:23255 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-5240
Practice Address - Country:US
Practice Address - Phone:734-287-3000
Practice Address - Fax:734-287-3113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003764208M00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC97618112Medicare ID - Type Unspecified