Healthcare Provider Details

I. General information

NPI: 1972077626
Provider Name (Legal Business Name): JESSICA MATTHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA KRUIZENGA

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 ARCADIA DR NE
GRAND RAPIDS MI
49525-2313
US

IV. Provider business mailing address

1301 ARCADIA DR NE
GRAND RAPIDS MI
49525-2313
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-5146
  • Fax:
Mailing address:
  • Phone: 616-259-5146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451017016
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: