Healthcare Provider Details

I. General information

NPI: 1376196667
Provider Name (Legal Business Name): JESSICA BROOKE HUNTZINGER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 QUARTZ ST
ONTONAGON MI
49953-1115
US

IV. Provider business mailing address

105 3RD ST
ONTONAGON MI
49953-1350
US

V. Phone/Fax

Practice location:
  • Phone: 906-884-4804
  • Fax: 906-884-4856
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704265639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: