Healthcare Provider Details

I. General information

NPI: 1194088377
Provider Name (Legal Business Name): KJC323PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

967 SPAULDING AVE SE SUITE E
ADA MI
49301-3700
US

IV. Provider business mailing address

967 SPAULDING AVE SE SUITE E
ADA MI
49301-3700
US

V. Phone/Fax

Practice location:
  • Phone: 616-464-4324
  • Fax: 616-949-5336
Mailing address:
  • Phone: 616-464-4324
  • Fax: 616-949-5336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013342
License Number StateMI

VIII. Authorized Official

Name: DR. KATHLEEN JANDERNOA CRAMER
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD,LP
Phone: 616-464-3424