Provider Demographics
NPI:1104920792
Name:WETZEL, JENNILYN (MD)
Entity type:Individual
Prefix:
First Name:JENNILYN
Middle Name:
Last Name:WETZEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28289 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5436
Mailing Address - Country:US
Mailing Address - Phone:248-585-8218
Mailing Address - Fax:248-585-8266
Practice Address - Street 1:30695 LITTLE MACK
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066
Practice Address - Country:US
Practice Address - Phone:586-294-9600
Practice Address - Fax:586-294-7570
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW054330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3123069Medicaid
MI3123069Medicaid
MI3123069Medicaid