Healthcare Provider Details

I. General information

NPI: 1588274336
Provider Name (Legal Business Name): JENNA BESON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 12/08/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

4498 S QUARTERLINE RD
MUSKEGON MI
49444-4243
US

V. Phone/Fax

Practice location:
  • Phone: 231-262-2145
  • Fax:
Mailing address:
  • Phone: 231-262-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: