Provider Demographics
NPI:1659334522
Name:KENYON, JEFFREY JAMES (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
Last Name:KENYON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 EAST PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8294
Mailing Address - Country:US
Mailing Address - Phone:616-949-8500
Mailing Address - Fax:616-949-2878
Practice Address - Street 1:2112 EAST PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-949-8500
Practice Address - Fax:616-949-2878
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4879094Medicaid
MIJK004316OtherBCBSM
MI4879094Medicaid
MIV06474Medicare UPIN
MIM67910004Medicare PIN