Healthcare Provider Details

I. General information

NPI: 1205223088
Provider Name (Legal Business Name): JANE BOOMSMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2786 56TH ST SW
WYOMING MI
49418-8708
US

IV. Provider business mailing address

7770 WILSON AVE SW
BYRON CENTER MI
49315-8650
US

V. Phone/Fax

Practice location:
  • Phone: 616-261-3960
  • Fax:
Mailing address:
  • Phone: 616-690-1241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202000514
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: