Healthcare Provider Details

I. General information

NPI: 1255677738
Provider Name (Legal Business Name): JENNIFER KINGSBURY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13105 SCHAVEY RD #4
DEWITT MI
48820-9037
US

IV. Provider business mailing address

1701 LAKE LANSING RD SUITE 100
LANSING MI
48912-3798
US

V. Phone/Fax

Practice location:
  • Phone: 517-668-0555
  • Fax:
Mailing address:
  • Phone: 517-485-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601003220
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: