Provider Demographics
NPI:1104863646
Name:JAKUBOWSKI, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:JAKUBOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 LAFAYETTE AVE SE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4656
Mailing Address - Country:US
Mailing Address - Phone:616-459-0801
Mailing Address - Fax:616-459-4065
Practice Address - Street 1:350 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4656
Practice Address - Country:US
Practice Address - Phone:616-459-0801
Practice Address - Fax:616-459-4065
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMJ043600225400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMJ043600OtherSTATE LICENSE
MI1839854Medicaid
A77037Medicare UPIN