Provider Demographics
NPI:1508875477
Name:WILLIFORD, JENNIFER M (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WILLIFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:LUCIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 OLD CENTRE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4883
Mailing Address - Country:US
Mailing Address - Phone:269-321-7546
Mailing Address - Fax:269-321-1705
Practice Address - Street 1:3000 OLD CENTRE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4883
Practice Address - Country:US
Practice Address - Phone:269-321-7546
Practice Address - Fax:269-321-1705
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003753363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M58330003Medicare PIN