Healthcare Provider Details

I. General information

NPI: 1609214972
Provider Name (Legal Business Name): JENNIFER LYNN KRISHNAN M.S. PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36800 WOODWARD AVE STE 112
BLOOMFIELD HILLS MI
48304-0916
US

IV. Provider business mailing address

915 N ALEXANDER AVE
ROYAL OAK MI
48067-3607
US

V. Phone/Fax

Practice location:
  • Phone: 947-274-8300
  • Fax: 947-243-3301
Mailing address:
  • Phone: 313-318-9590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601006682
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: