Healthcare Provider Details

I. General information

NPI: 1245856731
Provider Name (Legal Business Name): JENNIFER HOEKSTRA CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MAYBERRY ST SE
GRAND RAPIDS MI
49508-1525
US

IV. Provider business mailing address

1900 MAYBERRY ST SE
GRAND RAPIDS MI
49508-1525
US

V. Phone/Fax

Practice location:
  • Phone: 616-634-2405
  • Fax:
Mailing address:
  • Phone: 616-634-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number312802
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: