Healthcare Provider Details

I. General information

NPI: 1679657274
Provider Name (Legal Business Name): JENNIFER YIRSA WESTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 PATIENT CARE DR
LANSING MI
48911-4299
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 517-374-7600
  • Fax: 855-495-5457
Mailing address:
  • Phone: 517-364-6253
  • Fax: 517-364-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: