Provider Demographics
NPI:1336188556
Name:JAWOR, KATHERINE ANN (DO)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:JAWOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:17325 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-364-1500
Practice Address - Fax:616-364-6400
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010122702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383621541OtherASR
MI4765010Medicaid
MI2656100914OtherBCBS MI
MI102239OtherVALUE OPTIONS
MI214510000OtherMAGELLAN
MI4765010Medicaid
MIP46340001Medicare PIN
MI102239OtherVALUE OPTIONS
MID16083106Medicare PIN