Healthcare Provider Details

I. General information

NPI: 1902507908
Provider Name (Legal Business Name): JESSICA JOY MARVIN LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 FRONT AVE NW STE 100
GRAND RAPIDS MI
49504-5323
US

IV. Provider business mailing address

2084 FAWNWOOD DR SE
KENTWOOD MI
49508-6516
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-3711
  • Fax:
Mailing address:
  • Phone: 616-826-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6851116156
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: