Healthcare Provider Details

I. General information

NPI: 1447526272
Provider Name (Legal Business Name): DANIELLE KATHRYNE JANDERNOA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 3 MILE RD NW STE 2
GRAND RAPIDS MI
49544-8216
US

IV. Provider business mailing address

890 3 MILE RD NW STE 2
GRAND RAPIDS MI
49544-8216
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-2342
  • Fax: 616-369-3769
Mailing address:
  • Phone: 616-202-2342
  • Fax: 616-369-3769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093815
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: