Provider Demographics
NPI:1063266500
Name:DUSENBERRY, JIM (PTA)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:DUSENBERRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 GERMAINE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4199
Mailing Address - Country:US
Mailing Address - Phone:231-670-9677
Mailing Address - Fax:
Practice Address - Street 1:3322 GERMAINE RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-4199
Practice Address - Country:US
Practice Address - Phone:231-750-8480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004085208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation