MEDICARE: SUSAN JONGEKRYG LMSW LLC

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
1	1041C0700X	Clinical Social Worker	6801094737	MI

General Provider Information

NPI Number	:	1992174361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN JONGEKRYG LMSW LLC

Provider Business Mailing Address
First Line	:	6945 BELDING RD. NE
Second Line	:
City	:	ROCKFORD
State	:	MI
Zip	:	49341
Country	:	US
Telephone Number	:	616-329-3642
Fax Number	:

Provider Business Practice Location Address
First Line	:	3180 E PARIS AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1926
Country	:	US
Telephone Number	:	616-949-9006
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	SUSAN JONGEKRYG
Credential	:	LMSW
Telephone Number	:	616-949-9006

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	09/16/2015

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