Healthcare Provider Details

I. General information

NPI: 1417861469
Provider Name (Legal Business Name): JENNA WOLTHUIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4252 3 MILE RD NW
GRAND RAPIDS MI
49534-1135
US

IV. Provider business mailing address

3460 PEACH RIDGE AVE NW
GRAND RAPIDS MI
49544-9743
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-6351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number4704343818
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: