Healthcare Provider Details

I. General information

NPI: 1326967167
Provider Name (Legal Business Name): JORDAN KELLCIUT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 MONROE CENTER ST NW
GRAND RAPIDS MI
49503-2825
US

IV. Provider business mailing address

146 MONROE CENTER ST NW STE 425
GRAND RAPIDS MI
49503-2843
US

V. Phone/Fax

Practice location:
  • Phone: 616-209-8854
  • Fax:
Mailing address:
  • Phone: 269-779-9612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: