Healthcare Provider Details

I. General information

NPI: 1982567426
Provider Name (Legal Business Name): KRISTIN SHUCKEROW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7750 20TH AVE
JENISON MI
49428-8524
US

IV. Provider business mailing address

11670 SUNDROP CIR
ALLENDALE MI
49401-8443
US

V. Phone/Fax

Practice location:
  • Phone: 616-341-2997
  • Fax:
Mailing address:
  • Phone: 989-317-6911
  • Fax: 989-317-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: