Healthcare Provider Details

I. General information

NPI: 1477034841
Provider Name (Legal Business Name): JACOB ANDREW STILLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 3 MILE RD NW SUITE 200
GRAND RAPIDS MI
49544-1691
US

IV. Provider business mailing address

2738 ARDMORE ST SE
GRAND RAPIDS MI
49506-4919
US

V. Phone/Fax

Practice location:
  • Phone: 616-469-3870
  • Fax:
Mailing address:
  • Phone: 231-286-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001568
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: