Provider Demographics
NPI:1104323062
Name:DALTON, JENNIFER REBECCA (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:DALTON
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 DIANA ST
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1987
Mailing Address - Country:US
Mailing Address - Phone:231-845-6294
Mailing Address - Fax:
Practice Address - Street 1:920 DIANA ST
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1987
Practice Address - Country:US
Practice Address - Phone:231-845-6294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily