Healthcare Provider Details

I. General information

NPI: 1649673591
Provider Name (Legal Business Name): JESSICA WARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

5250 NORTHLAND DR NE STE A
GRAND RAPIDS MI
49525-1096
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone: 616-361-5000
  • Fax: 616-361-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: