1609968775 NPI number — MELISSA DAWN JOUSMA LMSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609968775 NPI number — MELISSA DAWN JOUSMA LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOUSMA
Provider First Name:
MELISSA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORREN
Provider Other First Name:
MELISSA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609968775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2745 1/2 84TH ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BYRON CENTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49315-8841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-856-0379
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 APPLE TREE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48846-7506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-527-1790
Provider Business Practice Location Address Fax Number:
616-527-0538
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6801085490 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6801085490 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1715928 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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