Basic Information
| Provider Information | |||||||||
| NPI: | 1912908997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOETJE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317275211 | ||||||||
| FaxNumber: | 2317274571 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 E COLBY ST | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494611262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285910 | ||||||||
| FaxNumber: | 2317285918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 12/19/2017 | ||||||||
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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 | 363AM0700X | 5601002222 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.