Healthcare Provider Details

I. General information

NPI: 1972165595
Provider Name (Legal Business Name): JONATHAN KEVIN ENGLUND LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 44TH ST SE
GRAND RAPIDS MI
49508-5002
US

IV. Provider business mailing address

541 BAYBERRY POINTE DR NW APT F
GRAND RAPIDS MI
49534-8005
US

V. Phone/Fax

Practice location:
  • Phone: 989-657-1272
  • Fax:
Mailing address:
  • Phone: 989-657-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801104266
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: