Provider Demographics
NPI:1750372033
Name:HOUTMAN, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HOUTMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4613 W MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2698
Mailing Address - Country:US
Mailing Address - Phone:269-349-2641
Mailing Address - Fax:
Practice Address - Street 1:4613 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2645
Practice Address - Country:US
Practice Address - Phone:269-488-8672
Practice Address - Fax:269-488-8673
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJH075631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA1068OtherRAILROAD MEDICARE
MIJH075631OtherSTATE LICENSE #
MI23904OtherHEALTH PLAN OF MI
MIP25914FOtherBLUE CARE NETWORK
01-31681OtherPHP PROV #
2334854OtherUNITED HEALTHCARE
MI5218152Medicaid
H83833Medicare UPIN
MI5218152Medicaid