Healthcare Provider Details

I. General information

NPI: 1740945328
Provider Name (Legal Business Name): JANE ELIZABETH DETWEILER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 KNAPP ST NE
GRAND RAPIDS MI
49525-9666
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-265-8241
  • Fax:
Mailing address:
  • Phone: 616-265-8241
  • Fax: 616-281-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009095
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: