Healthcare Provider Details

I. General information

NPI: 1033284278
Provider Name (Legal Business Name): JILL MARIE JOHNSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL MARIE GENGLE

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8333 FELCH ST SUITE 300
ZEELAND MI
49464-2608
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC- 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-994-6677
  • Fax: 616-494-5901
Mailing address:
  • Phone: 616-267-7400
  • Fax: 616-267-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: