Provider Demographics
NPI:1427438910
Name:JIRTLE, JENNIFER (RDH)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:JIRTLE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PRZYTULSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:404 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-1223
Mailing Address - Country:US
Mailing Address - Phone:269-792-0144
Mailing Address - Fax:269-792-0104
Practice Address - Street 1:404 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1223
Practice Address - Country:US
Practice Address - Phone:269-792-0144
Practice Address - Fax:269-792-0104
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014981124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174963375Medicaid