Basic Information
| Provider Information | |||||||||
| NPI: | 1780675140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIZZO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 N SAINT JOSEPH AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870808 | ||||||||
| FaxNumber: | 2696870811 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 N SAINT JOSEPH AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870808 | ||||||||
| FaxNumber: | 2696870811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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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 | 363LW0102X | 129854 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | 4704258909 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1780675140 | 05 | MI | MEDICAID |