Healthcare Provider Details

I. General information

NPI: 1154679348
Provider Name (Legal Business Name): AUDREY JAGT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

IV. Provider business mailing address

3525 PRATT LAKE AVE SE
LOWELL MI
49331-9376
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-0040
  • Fax:
Mailing address:
  • Phone: 616-446-7085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: