Healthcare Provider Details

I. General information

NPI: 1952146334
Provider Name (Legal Business Name): JANE ELIZABETH HOFSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1815 FOREST LAKE DR SE
GRAND RAPIDS MI
49546-6289
US

V. Phone/Fax

Practice location:
  • Phone: 516-456-6571
  • Fax:
Mailing address:
  • Phone: 616-430-4445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851118613
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: