Provider Demographics
NPI:1184015414
Name:LACKMAN, JENNIFER J (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:LACKMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:J
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:ATTN MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 LAFAYETTE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4693
Practice Address - Country:US
Practice Address - Phone:616-685-8200
Practice Address - Fax:616-685-8202
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007301363A00000X
CAPA55661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant