Provider Demographics
NPI:1952358160
Name:OPDYCKE, JENNIFER S (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:S
Last Name:OPDYCKE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 VENTURE CT STE A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2858
Mailing Address - Country:US
Mailing Address - Phone:269-220-0648
Mailing Address - Fax:269-220-3535
Practice Address - Street 1:5708 VENTURE CT STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2858
Practice Address - Country:US
Practice Address - Phone:269-220-0648
Practice Address - Fax:269-220-3535
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004149363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104840529OtherBCBSM - BMG
MI1952358160Medicaid
MIM37340009Medicare PIN
MIM20520118 - BMGMedicare PIN