Healthcare Provider Details

I. General information

NPI: 1992174361
Provider Name (Legal Business Name): SUSAN JONGEKRYG LMSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 E PARIS AVE SE
GRAND RAPIDS MI
49512-1926
US

IV. Provider business mailing address

6945 BELDING RD. NE
ROCKFORD MI
49341
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-9006
  • Fax:
Mailing address:
  • Phone: 616-329-3642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094737
License Number StateMI

VIII. Authorized Official

Name: SUSAN JONGEKRYG
Title or Position: CLINICAL SOCIAL WORKER
Credential: LMSW
Phone: 616-949-9006