Healthcare Provider Details

I. General information

NPI: 1750408902
Provider Name (Legal Business Name): JASON KENNEDY KAE-SMITH LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 36TH ST SE
GRAND RAPIDS MI
49548-2344
US

IV. Provider business mailing address

4381 MOORE RD
ALLEGAN MI
49010-8913
US

V. Phone/Fax

Practice location:
  • Phone: 616-475-8300
  • Fax:
Mailing address:
  • Phone: 269-686-2203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801081566
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: