Healthcare Provider Details

I. General information

NPI: 1407531015
Provider Name (Legal Business Name): JACOB JOHN ROBBINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 SIGSBEE ST SE
GRAND RAPIDS MI
49506-2556
US

IV. Provider business mailing address

1250 SIGSBEE ST SE
GRAND RAPIDS MI
49506-2556
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-3696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPP0000001079250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: