Provider Demographics
NPI:1265880140
Name:WOLLACK, JENNIFER MICHELLE (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:WOLLACK
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:KREZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3955 PATIENT CARE DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4299
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:885-480-9150
Practice Address - Street 1:3955 PATIENT CARE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4299
Practice Address - Country:US
Practice Address - Phone:517-374-7600
Practice Address - Fax:885-480-9150
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101022728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program