Healthcare Provider Details

I. General information

NPI: 1114223997
Provider Name (Legal Business Name): JILL RENAE EMMICK M.A. BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL MEISTE M.A. BCBA

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 E PARIS AVE SE STE 101
GRAND RAPIDS MI
49546-2414
US

IV. Provider business mailing address

2323 E PARIS AVE SE STE 101
GRAND RAPIDS MI
49546-2414
US

V. Phone/Fax

Practice location:
  • Phone: 616-610-5697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: