Provider Demographics
NPI:1700946654
Name:MERRITT-HACKEL, JENNIFER HAYDEN (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HAYDEN
Last Name:MERRITT-HACKEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 FURNACE BROOK PKWY
Mailing Address - Street 2:STE 31
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4787
Mailing Address - Country:US
Mailing Address - Phone:857-403-1181
Mailing Address - Fax:617-472-6947
Practice Address - Street 1:4260 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-2700
Practice Address - Country:US
Practice Address - Phone:734-764-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704131145363L00000X, 363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4270523Medicaid
MI0M97190018Medicare ID - Type Unspecified
MI4270523Medicaid