Provider Demographics
NPI:1780675140
Name:ZIZZO, JENNIFER LYNN (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ZIZZO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2203
Mailing Address - Country:US
Mailing Address - Phone:269-687-0808
Mailing Address - Fax:269-687-0811
Practice Address - Street 1:42 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2203
Practice Address - Country:US
Practice Address - Phone:269-687-0808
Practice Address - Fax:269-687-0811
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129854363LW0102X
MI4704258909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780675140Medicaid
MI1780675140Medicaid