Healthcare Provider Details

I. General information

NPI: 1821668476
Provider Name (Legal Business Name): JENNIFER MCKINSTRY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2021
Last Update Date: 06/27/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 KENMOOR AVE SE STE C
GRAND RAPIDS MI
49546-8624
US

IV. Provider business mailing address

959 DIAMOND AVE NE
GRAND RAPIDS MI
49503-1256
US

V. Phone/Fax

Practice location:
  • Phone: 616-558-6613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401019455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: