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General NPI Number Information
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NPI Number | 1891476107
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Entity Type | Individual
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Provider Name | REILLY JACOBSON TLLP
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Gender | Female
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Dates
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Enumeration Date | 07/28/2023
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Last Update Date | 07/28/2023
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Provider Practice Location Address
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Address Line | 640 3 MILE RD NW STE G
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-8209
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Country | US
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Telephone | 616-369-8433
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Fax |
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Provider Business Mailing Address
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Address Line | 158 WESTOWN DR NW APT 303
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City | GRAND RAPIDS
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State | MI
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Zip | 49534-3719
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Country | US
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Telephone | 515-468-1496
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6362009732
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License Number State | MI
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