Provider Demographics
NPI:1881646610
Name:TATE, JENNIFER L (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:TATE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-5211
Mailing Address - Fax:231-727-4571
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420
Practice Address - Country:US
Practice Address - Phone:231-873-5675
Practice Address - Fax:231-873-1825
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003148363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical