Healthcare Provider Details

I. General information

NPI: 1972361459
Provider Name (Legal Business Name): QUINN JENNIFER WILTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: QUINN KEILEN PA-C

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3570 HENRY ST STE 220
NORTON SHORES MI
49441-4576
US

IV. Provider business mailing address

3570 HENRY ST STE 220
NORTON SHORES MI
49441-4576
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-3155
  • Fax: 231-672-3157
Mailing address:
  • Phone: 231-672-3155
  • Fax: 231-672-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012228
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: