Basic Information
| Provider Information | |||||||||
| NPI: | 1356461107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815974 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 4160 JOHN R ST | ||||||||
| Address2: | SUITE 615 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137458773 | ||||||||
| FaxNumber: | 3139930595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 05/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5601002528 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 5601002528 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.