Healthcare Provider Details

I. General information

NPI: 1891742631
Provider Name (Legal Business Name): JEANNE M KAPENGA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 OKEMOS RD STE 6
OKEMOS MI
48864-2821
US

IV. Provider business mailing address

3805 HEMMINGWAY DR
OKEMOS MI
48864-3836
US

V. Phone/Fax

Practice location:
  • Phone: 616-822-5509
  • Fax:
Mailing address:
  • Phone: 616-822-5509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301406814
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number4301406814
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: