Healthcare Provider Details

I. General information

NPI: 1982193256
Provider Name (Legal Business Name): JACOB B NIENHUIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4488 JACKSON RD STE 7B
ANN ARBOR MI
48103
US

IV. Provider business mailing address

18 W WARNER ST
YPSILANTI MI
48197-4709
US

V. Phone/Fax

Practice location:
  • Phone: 616-856-0294
  • Fax:
Mailing address:
  • Phone: 616-856-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301016354
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: