Healthcare Provider Details

I. General information

NPI: 1124451141
Provider Name (Legal Business Name): KIUAN JHERNELL HEARNS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 LEONARD AVE NE
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

1560 LEONARD AVE NE
GRAND RAPIDS MI
49505
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax: 616-458-5640
Mailing address:
  • Phone: 616-456-6571
  • Fax: 616-458-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401012911
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401018116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: