Provider Demographics
NPI:1922445022
Name:DULANEY, JENNIFER KAY (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KAY
Last Name:DULANEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KAY
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-672-2120
Mailing Address - Fax:343-432-7758
Practice Address - Street 1:3570 HENRY ST STE 120
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-4576
Practice Address - Country:US
Practice Address - Phone:231-672-7000
Practice Address - Fax:231-728-5041
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101022190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N28430OtherGROUP MEDICARE PTAN