MEDICARE: MS. JENNIFER SUZANNE HOLLENBACK LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703120314	MI

General Provider Information

NPI Number	:	1518597079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER SUZANNE HOLLENBACK LPN

Provider Business Mailing Address
First Line	:	485 HUSTLER ST
Second Line	:
City	:	GWINN
State	:	MI
Zip	:	49841-2902
Country	:	US
Telephone Number	:	906-361-4140
Fax Number	:

Provider Business Practice Location Address
First Line	:	236 CANDACE DR
Second Line	:
City	:	HARVEY
State	:	MI
Zip	:	49855-9301
Country	:	US
Telephone Number	:	906-249-9492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2020
Last Update Date	:	01/23/2020

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