Healthcare Provider Details

I. General information

NPI: 1851763635
Provider Name (Legal Business Name): JESSICA ANNE VANDERWILP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

4100 EMBASSY DR SE STE 400
GRAND RAPIDS MI
49546-2416
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1730
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6251
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011525
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: