1881765071 NPI number — JILL WEGNER ACNP

Table of content: JILL WEGNER ACNP (NPI 1881765071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881765071 NPI number — JILL WEGNER ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEGNER
Provider First Name:
JILL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881765071
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6777 W MAPLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-3013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-325-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6777 W MAPLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-325-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  4704195321 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10-4680917 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10-4689035 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10-4689044 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10-4689008 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-4940999 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-4941010 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-4941029 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10-4689026 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-4941000 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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