Provider Demographics
NPI:1427507953
Name:BOUCK, JENNIFER A (AGNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BOUCK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:LESZCZYNSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6723
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:G3525 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1260
Practice Address - Country:US
Practice Address - Phone:810-222-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704231616363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology