MEDICARE: SUSAN F. JONGEKRYG LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801094737	MI

General Provider Information

NPI Number	:	1407103047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN F. JONGEKRYG LMSW

Provider Business Mailing Address
First Line	:	6945 BELDING RD NE
Second Line	:
City	:	ROCKFORD
State	:	MI
Zip	:	49341-8212
Country	:	US
Telephone Number	:	616-329-3642
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 3 MILE RD NW
Second Line	:	SUITE C
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-8218
Country	:	US
Telephone Number	:	616-647-3460
Fax Number	:	616-647-3467

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	05/15/2015

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