Healthcare Provider Details

I. General information

NPI: 1295667939
Provider Name (Legal Business Name): MACKENZIE JANE ROHM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 BURTON ST SE
GRAND RAPIDS MI
49546-6121
US

IV. Provider business mailing address

51 MATHEWS CT NE
GRAND RAPIDS MI
49505-4919
US

V. Phone/Fax

Practice location:
  • Phone: 616-301-8000
  • Fax:
Mailing address:
  • Phone: 616-291-2219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number230013600420707
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: