Provider Demographics
NPI:1053931873
Name:IDRISSU, JENNIFER R (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:IDRISSU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5280 METROPOLITAN PKWY
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4005
Mailing Address - Country:US
Mailing Address - Phone:248-290-3111
Mailing Address - Fax:248-290-3100
Practice Address - Street 1:3455 STARR RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2100
Practice Address - Country:US
Practice Address - Phone:248-288-9340
Practice Address - Fax:248-965-3029
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704245483363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner