Healthcare Provider Details

I. General information

NPI: 1740550037
Provider Name (Legal Business Name): JAMIE LEE DALTON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 COLLEGE AVE SE
GRAND RAPIDS MI
49507
US

IV. Provider business mailing address

2017 COLLEGE AVE SE
GRAND RAPIDS MI
49507-3101
US

V. Phone/Fax

Practice location:
  • Phone: 616-634-3301
  • Fax:
Mailing address:
  • Phone: 616-634-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801086476
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: