Healthcare Provider Details

I. General information

NPI: 1083183909
Provider Name (Legal Business Name): BETH ELLYN JEPSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 MONROE AVE NW STE 140
GRAND RAPIDS MI
49505-4609
US

IV. Provider business mailing address

2164 ARBOR TRL NW
WALKER MI
49534-7571
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-9520
  • Fax:
Mailing address:
  • Phone: 616-774-9405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: