Healthcare Provider Details

I. General information

NPI: 1306436316
Provider Name (Legal Business Name): DAWN J JENKINS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 01/23/2021
Certification Date: 01/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3282 CLEAR VISTA CT NE STE B
GRAND RAPIDS MI
49525-9766
US

IV. Provider business mailing address

1540 PONTIAC RD SE
GRAND RAPIDS MI
49506-3339
US

V. Phone/Fax

Practice location:
  • Phone: 616-901-5356
  • Fax:
Mailing address:
  • Phone: 616-901-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801086113
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: