Basic Information
Provider Information | |||||||||
NPI: | 1700805199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 W PATERSON ST | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490072557 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693492641 | ||||||||
FaxNumber: | 2694665522 | ||||||||
Practice Location | |||||||||
Address1: | 1035 E WILCOX AVE | ||||||||
Address2: |   | ||||||||
City: | WHITE CLOUD | ||||||||
State: | MI | ||||||||
PostalCode: | 49349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2316895943 | ||||||||
FaxNumber: | 2316891590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 09/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | JP080605 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 01072082A | IN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5217469 | 05 | MI |   | MEDICAID | 201135770 | 05 | IN |   | MEDICAID | 383218134 | 01 | MI | TRICARE | OTHER | 08-070-11602 | 01 | MI | BCBS | OTHER |