Provider Demographics
NPI:1144420381
Name:DEJONGE, HEATHER RENEE (MSPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:DEJONGE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 WYOMING AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-2233
Mailing Address - Country:US
Mailing Address - Phone:616-460-3955
Mailing Address - Fax:616-257-0853
Practice Address - Street 1:2511 WYOMING AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-2233
Practice Address - Country:US
Practice Address - Phone:616-460-3955
Practice Address - Fax:616-257-0853
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist