Provider Demographics
NPI:1174997563
Name:KUIPERS, JAKE EDWARD (ATC)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:EDWARD
Last Name:KUIPERS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 DEVONSHIRE DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4436
Mailing Address - Country:US
Mailing Address - Phone:616-307-4461
Mailing Address - Fax:
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:HEALTH AND HUMAN PERFORMANCE
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5200
Practice Address - Country:US
Practice Address - Phone:269-387-2703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010015222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer