=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063153484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOMIE GOERGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2022
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1818 W CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-5332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-377-4850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9523 W RS AVE
-----------------------------------------------------
City | SCHOOLCRAFT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49087-8428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-492-6471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOMARIE GOERGE
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 269-492-6473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------