Healthcare Provider Details

I. General information

NPI: 1326512468
Provider Name (Legal Business Name): JORDAN DAVID KUIPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE BLDG A
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

2608 MARBLE CT
ZEELAND MI
49464-8983
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-7775
  • Fax:
Mailing address:
  • Phone: 616-403-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: