Basic Information
| Provider Information | |||||||||
| NPI: | 1265551097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYCE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42557 WOODWARD AVE | ||||||||
| Address2: | STE 130 | ||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483045206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483223088 | ||||||||
| FaxNumber: | 2483224175 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WILLIAM CARLS DR | ||||||||
| Address2: | |||||||||
| City: | COMMERCE TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483822201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489374764 | ||||||||
| FaxNumber: | 2489374729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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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 | 363AM0700X | 5601002383 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | DS0605 | 01 | MI | RAIL ROAD MEDICARE GROUP PIN MHP | OTHER | MI4989416 | 01 | MI | MEDICARE PTAN MHP | OTHER | MI4989 | 01 | MI | MEDICARE GROUP PTAN MHP | OTHER | 1265551097 | 05 | MI | MEDICAID | 500H274490 | 01 | MI | BCBSM GROUP PIN MHP | OTHER |