Healthcare Provider Details

I. General information

NPI: 1912240482
Provider Name (Legal Business Name): JANNA KORTMAN CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4934 LUXEMBURG ST SE
GRAND RAPIDS MI
49546-8406
US

IV. Provider business mailing address

PO BOX 90002
WYOMING MI
49509-9919
US

V. Phone/Fax

Practice location:
  • Phone: 810-434-3339
  • Fax: 855-207-3270
Mailing address:
  • Phone: 810-434-3339
  • Fax: 855-207-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: