Provider Demographics
NPI:1740398346
Name:DUSTIN, JENNIFER KAY (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:DUSTIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-249-0750
Mailing Address - Fax:616-249-0794
Practice Address - Street 1:6500 BYRON CENTER AVE SW STE 202
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-9083
Practice Address - Country:US
Practice Address - Phone:616-249-0750
Practice Address - Fax:616-249-0794
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021225225100000X
MI5501012054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501012054OtherP.T. LICENSE