Basic Information
Provider Information | |||||||||
NPI: | 1750372033 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOUTMAN | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4613 W MAIN ST | ||||||||
Address2: | STE A | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490062698 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693492641 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4613 W MAIN ST | ||||||||
Address2: | SUITE A | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490062645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694888672 | ||||||||
FaxNumber: | 2694888673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2005 | ||||||||
LastUpdateDate: | 06/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | JH075631 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | CA1068 | 01 | MI | RAILROAD MEDICARE | OTHER | JH075631 | 01 | MI | STATE LICENSE # | OTHER | 23904 | 01 | MI | HEALTH PLAN OF MI | OTHER | P25914F | 01 | MI | BLUE CARE NETWORK | OTHER | 01-31681 | 01 |   | PHP PROV # | OTHER | 2334854 | 01 |   | UNITED HEALTHCARE | OTHER | 5218152 | 05 | MI |   | MEDICAID |