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General NPI Number Information
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NPI Number | 1326549916
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Entity Type | Individual
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Provider Name | JAIMIE LYNN COUCKE PA
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Gender | Female
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Dates
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Enumeration Date | 02/28/2018
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Last Update Date | 11/23/2022
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Provider Practice Location Address
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Address Line | 145 MICHIGAN ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2562
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Country | US
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Telephone | 616-486-5941
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Fax |
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Provider Business Mailing Address
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Address Line | 100 MICHIGAN ST NE # MC845
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2560
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 7101004357
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601011219
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License Number State | MI
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