Healthcare Provider Details

I. General information

NPI: 1164574430
Provider Name (Legal Business Name): JLS COUNSELING & MENTORING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2268 THISTLEDOWNE DR NE
GRAND RAPIDS MI
49505-6325
US

IV. Provider business mailing address

4310 LEONARD ST NW SUITE 103
WALKER MI
49534
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-9090
  • Fax:
Mailing address:
  • Phone: 616-453-6329
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080952
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704077527
License Number StateMI

VIII. Authorized Official

Name: JANE L STOCKINGER
Title or Position: OWNER
Credential: LMSW ACSW BSN RN
Phone: 616-940-9090