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General NPI Number Information
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NPI Number | 1588216048
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Entity Type | Individual
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Provider Name | KATHERINE JACK LPC
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Gender | Female
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Dates
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Enumeration Date | 07/15/2019
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Last Update Date | 04/19/2024
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Provider Practice Location Address
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Address Line | 3351 CLAYSTONE ST SE STE G32
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-5794
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Country | US
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Telephone | 616-259-6827
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Fax |
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Provider Business Mailing Address
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Address Line | 2042 INNWOOD DR SE
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City | KENTWOOD
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State | MI
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Zip | 49508-5066
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Country | US
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Telephone | 616-260-4597
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0019661
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401222851
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License Number State | MI
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