Healthcare Provider Details

I. General information

NPI: 1609317932
Provider Name (Legal Business Name): JAMIN GENTRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 36TH ST SE
GRAND RAPIDS MI
49548-2319
US

IV. Provider business mailing address

775 36TH ST
GRAND RAPIDS MI
49548
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-1917
  • Fax:
Mailing address:
  • Phone: 616-726-1917
  • 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: