Provider Demographics
NPI:1215129754
Name:ANDERSON, JENNIFER MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3235 N WELLNESS DR
Mailing Address - Street 2:STE 120A
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8035
Mailing Address - Country:US
Mailing Address - Phone:616-748-2850
Mailing Address - Fax:616-748-2855
Practice Address - Street 1:8333 FELCH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1698
Practice Address - Country:US
Practice Address - Phone:616-748-2850
Practice Address - Fax:616-748-2855
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08-5-70-1097-0OtherBCBS
MI5601003933OtherLICENSE