Basic Information
| Provider Information | |||||||||
| NPI: | 1245636711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUIKEMA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILKINS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2120 43RD ST SE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495083772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162811144 | ||||||||
| FaxNumber: | 6164568208 | ||||||||
| Practice Location | |||||||||
| Address1: | 9028 N RODGERS DR | ||||||||
| Address2: | SUITE J | ||||||||
| City: | CALEDONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493169786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168910600 | ||||||||
| FaxNumber: | 6164568208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 12/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501016950 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1245636711 | 05 | MI | MEDICAID |