Healthcare Provider Details

I. General information

NPI: 1861357519
Provider Name (Legal Business Name): JUSTIN JAY MONROE PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

4226 DEL MAR CT SW
WYOMING MI
49418-8737
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax:
Mailing address:
  • Phone: 517-803-1563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: