Provider Demographics
NPI:1437268448
Name:KOEBBE, JAN (NP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:KOEBBE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8719
Mailing Address - Fax:616-840-9637
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8719
Practice Address - Fax:616-840-9637
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704127360363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104545821Medicaid
MIJK127360OtherBLUE CROSS
MI104545821Medicaid