Healthcare Provider Details

I. General information

NPI: 1457884009
Provider Name (Legal Business Name): JAQUALE RHODES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 JACKSON AVE
MUSKEGON MI
49442-1114
US

IV. Provider business mailing address

349 JACKSON AVE
MUSKEGON MI
49442-1114
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-2397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JAQUALE RHODES
Title or Position: INDEPENDENT CONTRACTOR
Credential:
Phone: 616-259-2397