=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154860096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER TORNGA OTD, OTR/L, CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 12/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 36TH ST SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49512-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-799-5140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11530 WILMINGTON DR
-----------------------------------------------------
City | ALLENDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49401-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-379-1352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------