Healthcare Provider Details

I. General information

NPI: 1740246339
Provider Name (Legal Business Name): JACOBUS AM DONDERS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

235 WEALTHY SE
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-242-9201
  • Fax: 616-451-9513
Mailing address:
  • Phone: 616-242-9201
  • Fax: 616-451-9513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number6301007509
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: