Healthcare Provider Details

I. General information

NPI: 1124530449
Provider Name (Legal Business Name): JENNIFER SAMPSON MSN, RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BOHL

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BRIDGE ST
EAST JORDAN MI
49727-9383
US

IV. Provider business mailing address

1594 SEELEY RD NW
RAPID CITY MI
49676-9535
US

V. Phone/Fax

Practice location:
  • Phone: 231-536-2206
  • Fax:
Mailing address:
  • Phone: 989-573-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704302893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: