MEDICARE: JASON WILLIAM WULFF NP

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	363LA2200X	Adult Health Nurse Practitioner	4704235156	MI
2	163WG0000X	General Practice Registered Nurse	4704235156	MI

General Provider Information

NPI Number	:	1760615777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON WILLIAM WULFF NP

Provider Business Mailing Address
First Line	:	PO BOX 639295 DEPT 93394
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-9295
Country	:	US
Telephone Number	:	248-434-6169
Fax Number	:	855-618-6655

Provider Business Practice Location Address
First Line	:	500 KIRTS BLVD STE 100
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4135
Country	:	US
Telephone Number	:	248-824-6400
Fax Number	:	855-618-6655

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

Provider Enumeration Date	:	08/25/2009
Last Update Date	:	11/02/2023

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