Provider Demographics
NPI:1912908997
Name:KOETJE, JENNIFER J (PA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:J
Last Name:KOETJE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:116 W COLBY ST STE D
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1084
Mailing Address - Country:US
Mailing Address - Phone:231-292-1240
Mailing Address - Fax:231-292-1088
Practice Address - Street 1:116 W COLBY ST STE D
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1084
Practice Address - Country:US
Practice Address - Phone:231-292-1240
Practice Address - Fax:231-292-1088
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2024-01-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002222363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR66562Medicare UPIN
MI0M32670P05Medicare ID - Type Unspecified