Provider Demographics
NPI:1942561667
Name:KING, JENNIFER K (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-727-5211
Mailing Address - Fax:231-727-4571
Practice Address - Street 1:1675 LEAHY ST STE 401A
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5547
Practice Address - Country:US
Practice Address - Phone:231-727-4243
Practice Address - Fax:231-727-4214
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1763057OtherMEDICARE PTAN