Healthcare Provider Details

I. General information

NPI: 1184168312
Provider Name (Legal Business Name): JESSICA VANDENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 CASCADE RD SE STE A
GRAND RAPIDS MI
49546-3808
US

IV. Provider business mailing address

2051 GRIGGS ST SE
GRAND RAPIDS MI
49506-4608
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-0950
  • Fax:
Mailing address:
  • Phone: 616-954-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: