Healthcare Provider Details

I. General information

NPI: 1346743416
Provider Name (Legal Business Name): JASON VREDEVELD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BYRON CENTER AVE SW
WYOMING MI
49519-9606
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-7199
  • Fax:
Mailing address:
  • Phone: 616-252-7199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017054
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: