Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | 6301007509 | MI |
NPI | 1740246339 |
---|---|
Provider Name | Dr. Jacobus Am Donders |
First Address | Grand Rapids, MI 49503 |
Second Address | Grand Rapids, MI 49503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
JD007509 | PRIORITY HEALTH BLUE CROS (01) |