Provider Demographics
NPI:1265980023
Name:LISBON, JENAYE LARON (FNP)
Entity type:Individual
Prefix:MRS
First Name:JENAYE
Middle Name:LARON
Last Name:LISBON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7442 RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3652
Mailing Address - Country:US
Mailing Address - Phone:313-623-1541
Mailing Address - Fax:
Practice Address - Street 1:7700 SECOND AVENUE
Practice Address - Street 2:WELLNESS PLAN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-202-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704238010363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily