Basic Information
| Provider Information | |||||||||
| NPI: | 1104920792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WETZEL | ||||||||
| FirstName: | JENNILYN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28289 HOOVER RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480935436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485858218 | ||||||||
| FaxNumber: | 2485858266 | ||||||||
| Practice Location | |||||||||
| Address1: | 30695 LITTLE MACK | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862949600 | ||||||||
| FaxNumber: | 5862947570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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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 | 207Q00000X | JW054330 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3123069 | 05 | MI | MEDICAID |