Healthcare Provider Details

I. General information

NPI: 1205202025
Provider Name (Legal Business Name): JENNIFER BURGTORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2015
Last Update Date: 10/09/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25000 HALL RD STE 1
WOODHAVEN MI
48183-5112
US

IV. Provider business mailing address

25000 HALL RD STE 1
WOODHAVEN MI
48183-5112
US

V. Phone/Fax

Practice location:
  • Phone: 734-676-3373
  • Fax:
Mailing address:
  • Phone: 734-676-3373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704286508
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704286508
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704286508
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: