Healthcare Provider Details

I. General information

NPI: 1174997563
Provider Name (Legal Business Name): JAKE EDWARD KUIPERS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 W MICHIGAN AVE HEALTH AND HUMAN PERFORMANCE
KALAMAZOO MI
49008-5200
US

IV. Provider business mailing address

2244 DEVONSHIRE DR NE
GRAND RAPIDS MI
49505-4436
US

V. Phone/Fax

Practice location:
  • Phone: 269-387-2703
  • Fax:
Mailing address:
  • Phone: 616-307-4461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001522
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: