Provider Demographics
NPI:1750535373
Name:DE BOER, JACK (CCC-A)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:DE BOER
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 CHESANING DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-5309
Mailing Address - Country:US
Mailing Address - Phone:616-819-3070
Mailing Address - Fax:616-819-3239
Practice Address - Street 1:2036 CHESANING DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-5309
Practice Address - Country:US
Practice Address - Phone:616-819-3070
Practice Address - Fax:616-819-3239
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000343231H00000X, 237600000X
MI1601000342231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter