Provider Demographics
NPI:1144257171
Name:JAGGERS, KIM MARIE (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:JAGGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2000 GREEN ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1571
Mailing Address - Country:US
Mailing Address - Phone:734-995-3764
Mailing Address - Fax:734-995-2913
Practice Address - Street 1:5301 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI054260207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103458703Medicaid
MIKJ054260OtherBLUE SHIELD
MI104482070Medicaid
MI103372663Medicaid
F40151Medicare UPIN
MI104482070Medicaid