Provider Demographics
NPI:1265551097
Name:BRYCE, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRYCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42557 WOODWARD AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5206
Mailing Address - Country:US
Mailing Address - Phone:248-322-3088
Mailing Address - Fax:248-322-4175
Practice Address - Street 1:1 WILLIAM CARLS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-937-4764
Practice Address - Fax:248-937-4729
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002383363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDS0605OtherRAIL ROAD MEDICARE GROUP PIN MHP
MIMI4989416OtherMEDICARE PTAN MHP
MIMI4989OtherMEDICARE GROUP PTAN MHP
MI1265551097Medicaid
MI500H274490OtherBCBSM GROUP PIN MHP
MIMI4989416OtherMEDICARE PTAN MHP
MI1265551097Medicaid