Healthcare Provider Details

I. General information

NPI: 1124491055
Provider Name (Legal Business Name): ANGELA IACOBONI LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 BALDWIN ST
JENISON MI
49428-8901
US

IV. Provider business mailing address

6915 BREWER AVE NE
ROCKFORD MI
49341-9213
US

V. Phone/Fax

Practice location:
  • Phone: 616-457-0016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092970
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: