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NPI Code Detail

MEDICARE: JACK TOWN

MEDICARE: JACK TOWN
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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1447117049
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK TOWN
Provider Business Mailing Address
First Line : 5630 LAKE MICHIGAN DR STE B
Second Line :
City : ALLENDALE
State : MI
Zip : 49401-8115
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5630 LAKE MICHIGAN DR STE B
Second Line :
City : ALLENDALE
State : MI
Zip : 49401-8115
Country : US
Telephone Number : 616-566-1917
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/06/2026
Last Update Date : 01/06/2026

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Directions to “ JACK TOWN ” Practice Location

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