Provider Demographics
NPI:1154385797
Name:WHITE, JENNIFER SUE (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 E PARIS AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1154
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704231087363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008702080OtherBLUE CROSS BLUE SHIELD
P00083556OtherRAILROAD MEDICARE
MI4582350Medicaid
MI4507487Medicaid
MI5008702080OtherBLUE CROSS BLUE SHIELD
P80441Medicare UPIN