Healthcare Provider Details

I. General information

NPI: 1316403678
Provider Name (Legal Business Name): AMANDA COLLEY JACOBSON LPC, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MONROE AVE NW STE 217
GRAND RAPIDS MI
49503-1451
US

IV. Provider business mailing address

4593 CANTERWOOD DR NE
ADA MI
49301-8712
US

V. Phone/Fax

Practice location:
  • Phone: 248-935-5135
  • Fax:
Mailing address:
  • Phone: 248-935-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401019189
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: