Healthcare Provider Details

I. General information

NPI: 1780675140
Provider Name (Legal Business Name): JENNIFER LYNN ZIZZO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N SAINT JOSEPH AVE SUITE 201
NILES MI
49120-2203
US

IV. Provider business mailing address

42 N SAINT JOSEPH AVE SUITE 201
NILES MI
49120-2203
US

V. Phone/Fax

Practice location:
  • Phone: 269-687-0808
  • Fax: 269-687-0811
Mailing address:
  • Phone: 269-687-0808
  • Fax: 269-687-0811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number129854
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704258909
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: