Provider Demographics
NPI:1043861040
Name:EDWARDS, JENNIFER A (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 LAKE MICHIGAN DR NW STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-6300
Mailing Address - Country:US
Mailing Address - Phone:616-608-9978
Mailing Address - Fax:
Practice Address - Street 1:5819 BALSAM DR
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1104
Practice Address - Country:US
Practice Address - Phone:616-209-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501004400OtherLICENSE