Provider Demographics
NPI:1497833446
Name:KINGSLEY, JOANNE RUTH (MD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:RUTH
Last Name:KINGSLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 HORTON RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5594
Mailing Address - Country:US
Mailing Address - Phone:517-782-7510
Mailing Address - Fax:517-782-7520
Practice Address - Street 1:1931 HORTON RD
Practice Address - Street 2:SUITE 8
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-5594
Practice Address - Country:US
Practice Address - Phone:517-782-7510
Practice Address - Fax:517-782-7520
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK045630207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0720045OtherPHP PROVIDER NUMBER
MI104778547Medicaid
MI300326016OtherTAX ID #
MI1603811241OtherBCBS PROVIDER NUMBER
MI300326016OtherTAX ID #
MI104778547Medicaid