Provider Demographics
NPI:1184168312
Name:VANDENBERG, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 GRIGGS ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4608
Mailing Address - Country:US
Mailing Address - Phone:616-954-0950
Mailing Address - Fax:
Practice Address - Street 1:5060 CASCADE RD SE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3808
Practice Address - Country:US
Practice Address - Phone:616-954-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist