Provider Demographics
NPI:1457567158
Name:DICKINSON, JAMIE LYNN (PA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:SCHRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15100 WHITTAKER WAY
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8696
Practice Address - Country:US
Practice Address - Phone:616-935-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004993363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004993OtherST LICENSE
MI5601004993OtherST LICENSE