Healthcare Provider Details

I. General information

NPI: 1285073924
Provider Name (Legal Business Name): JENNIFER MARIE LAKE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2013
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1346 BALDWIN ST
JENISON MI
49428-8937
US

IV. Provider business mailing address

5638 LINEDRIVE CT NE
COMSTOCK PARK MI
49321-9626
US

V. Phone/Fax

Practice location:
  • Phone: 616-765-8585
  • Fax:
Mailing address:
  • Phone: 616-540-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704248401
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704248401
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: