Healthcare Provider Details

I. General information

NPI: 1073264891
Provider Name (Legal Business Name): JESSICA DANIELLE KREBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1700 ROBBINS RD LOT 207
GRAND HAVEN MI
49417-2856
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax:
Mailing address:
  • Phone: 616-566-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801106502
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: