Provider Demographics
NPI:1215308978
Name:GATES, JENNIFER ANNE (NNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:GATES
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 REEDS LAKE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2053
Mailing Address - Country:US
Mailing Address - Phone:517-896-8193
Mailing Address - Fax:
Practice Address - Street 1:1200 E. MICHIGAN AVE
Practice Address - Street 2:SPARROW HOSPITAL
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278655363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215308978Medicaid