Provider Demographics
NPI:1184610669
Name:ROOSSIEN, JACK RICHARD JR (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:RICHARD
Last Name:ROOSSIEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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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:866-611-1612
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:15151 STANTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST OLIVE
Practice Address - State:MI
Practice Address - Zip Code:49460-8543
Practice Address - Country:US
Practice Address - Phone:616-296-1020
Practice Address - Fax:616-296-1030
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIJR050437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION13120OtherMEDICARE GROUP NUMBER
MI4214810Medicaid
MI1184610669Medicaid
MI4214810Medicaid