Individual
JENNIFER J LACKMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
310 LAFAYETTE AVE SE, GRAND RAPIDS, MI 49503-4693
(616) 685-8200
(616) 685-8202
Mailing address
5900 BYRON CENTER AVE SW, ATTN MEDICAL ADMINISTRATION, WYOMING, MI 49519-9606
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
5601007301
MI
363A00000X
Physician Assistant
Primary
PA55661
CA
Other
Enumeration date
02/09/2015
Last updated
04/06/2022
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