Provider Demographics
NPI:1063742518
Name:JEPSEN, JOANNE LOIS (ANP-BC)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:LOIS
Last Name:JEPSEN
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 RAYBROOK AVE SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-340-9763
Mailing Address - Fax:
Practice Address - Street 1:2100 RAYBROOK AVE SE
Practice Address - Street 2:SUITE 300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-340-9763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704177140363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI153161730Medicaid
MIMI2492002Medicare Oscar/Certification