Provider Demographics
NPI:1174944235
Name:CAMERON, JENNIFER MARIE (CNM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CAMERON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1233
Mailing Address - Country:US
Mailing Address - Phone:231-299-3014
Mailing Address - Fax:231-299-3025
Practice Address - Street 1:110 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1233
Practice Address - Country:US
Practice Address - Phone:231-299-3014
Practice Address - Fax:231-299-3025
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704196999367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174944235Medicaid