Provider Demographics
NPI:1518216308
Name:KOOIENGA, JACK A (APRN)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:A
Last Name:KOOIENGA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:985 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9563
Mailing Address - Country:US
Mailing Address - Phone:616-252-4655
Mailing Address - Fax:616-252-0103
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-252-7200
Practice Address - Fax:616-252-7830
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704218318363LC0200X
FLAPRN11012762363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110773300Medicaid
MI0M33350Medicare PIN