Provider Demographics
NPI:1275591414
Name:EKKENS, JENNIFER J (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:EKKENS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX Q
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-4917
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015656207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJE015656OtherBCBS
MI4827383Medicaid
MI4827392Medicaid
MI4827409Medicaid
MI5201638Medicaid
MI1598712390OtherGROUP NPI
MI4827418Medicaid
MIP00415675OtherRAILROAD MEDICARE
MI4827374Medicaid
MI4827418Medicaid
I48976Medicare UPIN
MI4827392Medicaid