Healthcare Provider Details

I. General information

NPI: 1376331074
Provider Name (Legal Business Name): JULIE LYNN JENDRASIAK HAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 FOREST HILL CT SE
GRAND RAPIDS MI
49546-2389
US

IV. Provider business mailing address

833 KENMOOR AVE SE STE G
GRAND RAPIDS MI
49546-2390
US

V. Phone/Fax

Practice location:
  • Phone: 616-581-0761
  • Fax:
Mailing address:
  • Phone: 616-581-0761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3501004961
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: