Healthcare Provider Details

I. General information

NPI: 1801949979
Provider Name (Legal Business Name): JULIA BERNICE DE JONGE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4469 CASCADE RD SE SUITE 4469
GRAND RAPIDS MI
49546-3632
US

IV. Provider business mailing address

4469 CASCADE RD SE SUITE 4469
GRAND RAPIDS MI
49546-3632
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-3331
  • Fax:
Mailing address:
  • Phone: 616-940-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1816731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: