Provider Demographics
NPI:1811546229
Name:WILLE, JENNIFER MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:WILLE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:PONKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1675 NORTHUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-2962
Mailing Address - Country:US
Mailing Address - Phone:313-378-3903
Mailing Address - Fax:248-270-3368
Practice Address - Street 1:1701 E SOUTH BLVD SUITE 300
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6122
Practice Address - Country:US
Practice Address - Phone:248-884-9710
Practice Address - Fax:248-884-9711
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009658363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant