Healthcare Provider Details

I. General information

NPI: 1396969754
Provider Name (Legal Business Name): HULST JEPSEN PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3282 CLEAR VISTA CT NE SUITE A
GRAND RAPIDS MI
49525-9477
US

IV. Provider business mailing address

2120 43RD ST SE SUITE 100
GRAND RAPIDS MI
49508-3772
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-2709
  • Fax: 616-365-3174
Mailing address:
  • Phone: 616-281-1144
  • Fax: 616-281-1221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501004694
License Number StateMI

VIII. Authorized Official

Name: THOMAS J HULST
Title or Position: PRESIDENT
Credential: PT
Phone: 616-281-1144