Healthcare Provider Details

I. General information

NPI: 1588994701
Provider Name (Legal Business Name): JESSICA MARIE CLOUTIER M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA CHAMBERLIN LLPC

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 3 MILE RD NW
GRAND RAPIDS MI
49544-8209
US

IV. Provider business mailing address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507-2459
US

V. Phone/Fax

Practice location:
  • Phone: 616-785-8900
  • Fax:
Mailing address:
  • Phone: 616-247-3815
  • Fax: 616-245-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011184
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: