Healthcare Provider Details

I. General information

NPI: 1922658103
Provider Name (Legal Business Name): JENNIFER ANNE DUKARSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4696
US

IV. Provider business mailing address

2520 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4696
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-4000
  • Fax:
Mailing address:
  • Phone: 616-735-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000775
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: