Provider Demographics
NPI:1700805199
Name:PARKS, JENNIFER J (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:PARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 W PATERSON ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-2557
Mailing Address - Country:US
Mailing Address - Phone:269-349-2641
Mailing Address - Fax:269-466-5522
Practice Address - Street 1:1035 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349
Practice Address - Country:US
Practice Address - Phone:231-689-5943
Practice Address - Fax:231-689-1590
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP080605207Q00000X
IN01072082A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5217469Medicaid
IN201135770Medicaid
MI383218134OtherTRICARE
MI08-070-11602OtherBCBS
IN201135770Medicaid
MIOM56180017Medicare PIN