Healthcare Provider Details

I. General information

NPI: 1962173039
Provider Name (Legal Business Name): JILL GUNDERSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6147 28TH ST SE
GRAND RAPIDS MI
49546-6934
US

IV. Provider business mailing address

3777 BUTTRICK AVE SE
ADA MI
49301-9221
US

V. Phone/Fax

Practice location:
  • Phone: 616-207-3075
  • Fax:
Mailing address:
  • Phone: 616-460-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801111192
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: