Healthcare Provider Details

I. General information

NPI: 1669882726
Provider Name (Legal Business Name): JANELLE MCKINNON MSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 01/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 LEONARD ST NE
GRAND RAPIDS MI
49503-1138
US

IV. Provider business mailing address

1516 COLORADO AVE SE
GRAND RAPIDS MI
49507-2215
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-2021
  • Fax: 616-451-8936
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096586
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: