Healthcare Provider Details

I. General information

NPI: 1104534874
Provider Name (Legal Business Name): JENNIFER MARIE POLING LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N EVERGREEN DR NE STE 301
GRAND RAPIDS MI
49525-9334
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-1500
  • Fax: 616-364-6400
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801102056
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801116198
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: