Healthcare Provider Details

I. General information

NPI: 1023460367
Provider Name (Legal Business Name): JENNIFER EMILY LEWIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER EMILY ROSE RN

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 LAKESHIRE TRL
ADRIAN MI
49221-1561
US

IV. Provider business mailing address

718 LAKESHIRE TRAIL
ADRIAN MI
49221
US

V. Phone/Fax

Practice location:
  • Phone: 517-265-0600
  • Fax:
Mailing address:
  • Phone: 517-265-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704196130
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704196130
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: