Healthcare Provider Details

I. General information

NPI: 1033473749
Provider Name (Legal Business Name): JON RUSSELL KRUEGER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 07/21/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 5TH AVE
FLINT MI
48503-2445
US

IV. Provider business mailing address

420 W 5TH AVE
FLINT MI
48503-2445
US

V. Phone/Fax

Practice location:
  • Phone: 810-257-3736
  • Fax: 989-723-1205
Mailing address:
  • Phone: 810-257-3736
  • Fax: 989-723-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704205426
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: