Healthcare Provider Details

I. General information

NPI: 1881852390
Provider Name (Legal Business Name): JENNIFER LYNN UNDERWOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-0002
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4811
  • Fax:
Mailing address:
  • Phone: 517-841-6913
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006534RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: