1629400353 NPI number — MS. JENNIFER CHRISTINA MACK LMSW

Table of content: MS. JENNIFER CHRISTINA MACK LMSW (NPI 1629400353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629400353 NPI number — MS. JENNIFER CHRISTINA MACK LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACK
Provider First Name:
JENNIFER
Provider Middle Name:
CHRISTINA
Provider Name Prefix Text:
MS.
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:
DRISCOLL
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
CHRISTINA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LLMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629400353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 BALL AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-558-9534
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 BALL AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-558-9534
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2013

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: 1041C0700X , with the licence number:  6801095436 , 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)





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