Healthcare Provider Details

I. General information

NPI: 1720535552
Provider Name (Legal Business Name): JENNIFER DESTEFANO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BEZRUTCH NP

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 CADIEUX RD
GROSSE POINTE MI
48230-1507
US

IV. Provider business mailing address

2879 ROUNDTREE DR
TROY MI
48083-2331
US

V. Phone/Fax

Practice location:
  • Phone: 313-473-1000
  • Fax:
Mailing address:
  • Phone: 586-604-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704282745
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: