Provider Demographics
NPI:1609804715
Name:DRISCOLL, JENNIFER MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:DRISCOLL
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 1:4613 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2645
Mailing Address - Country:US
Mailing Address - Phone:269-488-8672
Mailing Address - Fax:269-488-8673
Practice Address - Street 1:4613 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2645
Practice Address - Country:US
Practice Address - Phone:269-488-8672
Practice Address - Fax:269-488-8673
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079562207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1103912432OtherBCBS IND PIN
MI489567910Medicaid
110C913020OtherBCBS GRP PIN
157805OtherGREAT LAKES HLTH PLN
MI489567910Medicaid
1103912432OtherBCBS IND PIN
MI0C97625094Medicare ID - Type Unspecified