Basic Information
| Provider Information | |||||||||
| NPI: | 1467607622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOFFMEYER | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490131246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694277937 | ||||||||
| FaxNumber: | 2694275180 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 M 139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490223881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699275400 | ||||||||
| FaxNumber: | 2699275493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 13792 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 71003208A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 4704284732 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.