Provider Demographics
NPI:1306295936
Name:BIENZ, JENNIFER NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:BIENZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:GATELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3440 CHICAGO DR STE 105
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1419
Mailing Address - Country:US
Mailing Address - Phone:616-796-9560
Mailing Address - Fax:
Practice Address - Street 1:3440 CHICAGO DR STE 105
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1419
Practice Address - Country:US
Practice Address - Phone:616-796-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-04
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007835363A00000X
WA60659929363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant