MEDICARE: MRS. JENNIFER J. KOETJE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	5601002222	MI

General Provider Information

NPI Number	:	1912908997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER J. KOETJE PA

Provider Business Mailing Address
First Line	:	116 W COLBY ST STE D
Second Line	:
City	:	WHITEHALL
State	:	MI
Zip	:	49461-1084
Country	:	US
Telephone Number	:	231-292-1240
Fax Number	:	231-292-1088

Provider Business Practice Location Address
First Line	:	116 W COLBY ST STE D
Second Line	:
City	:	WHITEHALL
State	:	MI
Zip	:	49461-1084
Country	:	US
Telephone Number	:	231-292-1240
Fax Number	:	231-292-1088

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	01/21/2024

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