Healthcare Provider Details

I. General information

NPI: 1699867895
Provider Name (Legal Business Name): JENNY LYNN BUSH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-8200
  • Fax: 616-940-5340
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-940-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301082271
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: