Healthcare Provider Details

I. General information

NPI: 1124013859
Provider Name (Legal Business Name): JENNIFER PLATKUS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 406
SOUTHFIELD MI
48075-4825
US

IV. Provider business mailing address

22250 PROVIDENCE DR STE 406
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 248-557-9010
  • Fax: 248-557-3655
Mailing address:
  • Phone: 248-557-9010
  • Fax: 248-557-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704195094
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: