Healthcare Provider Details

I. General information

NPI: 1518485853
Provider Name (Legal Business Name): JENNIFER ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 36TH ST SE STE 400
GRAND RAPIDS MI
49508-5581
US

IV. Provider business mailing address

901 EASTERN AVE NE
GRAND RAPIDS MI
49503-1201
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8158
  • Fax:
Mailing address:
  • Phone: 616-279-1975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014168
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: