Provider Demographics
NPI:1609930262
Name:KELLOGG, JENNIFER LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2221 HEALTH DRIVE SW
Practice Address - Street 2:SUITE 2100
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-252-4410
Practice Address - Fax:616-252-4480
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA6324363A00000X
MI5601004257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant