Healthcare Provider Details

I. General information

NPI: 1205492774
Provider Name (Legal Business Name): KARLI JO VANRYSWYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAURENCE AVE STE E
JACKSON MI
49202-2980
US

IV. Provider business mailing address

1001 LAURENCE AVE STE E
JACKSON MI
49202-2980
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-4777
  • Fax:
Mailing address:
  • Phone: 517-750-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number7402000156
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101008906
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: