Provider Demographics
NPI:1346709052
Name:DUFF, JENEAL M (PA-C)
Entity Type:Individual
Prefix:
First Name:JENEAL
Middle Name:M
Last Name:DUFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 OLIVIA ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5894
Mailing Address - Country:US
Mailing Address - Phone:317-670-2912
Mailing Address - Fax:
Practice Address - Street 1:2373 64TH ST SW STE 1300
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-7975
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006970363AM0700X
MI5601012103363AM0700X
IL085006970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601012103OtherSTATE LICENSE
IL1159852OtherSPECIALTY BOARDS
MI5315244931OtherCS LICENSE
IL385005452OtherCS LICENSE
IL085006970OtherSTATE LICENSE