Provider Demographics
NPI:1942931118
Name:GRAZEWSKI, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GRAZEWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 EASTCASTLE DR SE STE B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-8873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2013 EASTCASTLE DR SE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-8873
Practice Address - Country:US
Practice Address - Phone:616-888-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2024-10-22
Deactivation Date:2024-10-15
Deactivation Code:
Reactivation Date:2024-10-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator