Healthcare Provider Details

I. General information

NPI: 1881354041
Provider Name (Legal Business Name): DUSTIN JEPKEMA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DUSTY JEPKEMA

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 PORTAGE ST
KALAMAZOO MI
49001-3836
US

IV. Provider business mailing address

618 E STOCKBRIDGE AVE
KALAMAZOO MI
49001-2207
US

V. Phone/Fax

Practice location:
  • Phone: 269-312-0865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109544
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: