Provider Demographics
NPI:1588098685
Name:GREVENSTUK, JESSICA STARR (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:STARR
Last Name:GREVENSTUK
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:VANAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3235 N WELLNESS DR STE 120B
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8035
Mailing Address - Country:US
Mailing Address - Phone:616-399-9522
Mailing Address - Fax:
Practice Address - Street 1:3200 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1805
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704257219363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology