Provider Demographics
NPI:1801101159
Name:LEGGE, JENNIFER MELISSA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MELISSA
Last Name:LEGGE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:MELISSA
Other - Last Name:WOOTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:4967 CROOKS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:1548 HOLLYWOOD AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1310
Practice Address - Country:US
Practice Address - Phone:586-601-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704233177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily