Basic Information
| Provider Information | |||||||||
| NPI: | 1740260330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEWETT | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | SUITE M124 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417500 | ||||||||
| FaxNumber: | 2693417540 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | SUITE M124 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417500 | ||||||||
| FaxNumber: | 2693417540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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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 | 2084N0400X | 4301036495 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2602070 | 05 | MI | MEDICAID | CK6240 | 01 | MI | RAILROAD MEDICARE | OTHER |