Basic Information
| Provider Information | |||||||||
| NPI: | 1770867657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WERTH | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD A201 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 E. MICHIGAN AVE | ||||||||
| Address2: | TRAUMA CENTER | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173641000 | ||||||||
| FaxNumber: | 5173643525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2011 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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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 | 363LF0000X | 4704263382 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1770867657 | 05 | MI | MEDICAID |