Healthcare Provider Details

I. General information

NPI: 1336340140
Provider Name (Legal Business Name): JERRY BERNARD VANLEEUWEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JERRY B. VANLEEUWEN PHD, PC

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 28TH ST SE STE M
GRAND RAPIDS MI
49546-6966
US

IV. Provider business mailing address

6255 28TH ST SE STE M
GRAND RAPIDS MI
49546-6966
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-5294
  • Fax: 616-458-5295
Mailing address:
  • Phone: 616-458-5294
  • Fax: 616-458-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number4101000398
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301003978
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: