Provider Demographics
NPI:1245636711
Name:BUIKEMA, JESSICA LEE (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:BUIKEMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:WILKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3772
Mailing Address - Country:US
Mailing Address - Phone:616-281-1144
Mailing Address - Fax:616-456-8208
Practice Address - Street 1:9028 N RODGERS DR
Practice Address - Street 2:SUITE J
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9786
Practice Address - Country:US
Practice Address - Phone:616-891-0600
Practice Address - Fax:616-456-8208
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245636711Medicaid
MIM51600024Medicare PIN