Provider Demographics
NPI:1720094790
Name:JENNINGS, PAMELA (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:JENNINGS
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 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-577-3313
Mailing Address - Fax:947-577-3302
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:FSC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-423-2454
Practice Address - Fax:248-423-2454
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140788363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4823419Medicaid
MI500F318190OtherBCBSM