Healthcare Provider Details

I. General information

NPI: 1265880140
Provider Name (Legal Business Name): JENNIFER MICHELLE WOLLACK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MICHELLE KREZA

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 PATIENT CARE DR
LANSING MI
48911-4299
US

IV. Provider business mailing address

3955 PATIENT CARE DR
LANSING MI
48911-4299
US

V. Phone/Fax

Practice location:
  • Phone: 517-374-7600
  • Fax: 885-480-9150
Mailing address:
  • Phone: 517-374-7600
  • Fax: 885-480-9150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101022728
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: