Provider Demographics
NPI:1275988974
Name:KIEKINTVELD, JESSICA (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KIEKINTVELD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:POEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:58 BROOKMEADOW NORTH LN SW
Mailing Address - Street 2:APT 6
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3324
Mailing Address - Country:US
Mailing Address - Phone:231-557-7630
Mailing Address - Fax:
Practice Address - Street 1:58 BROOKMEADOW NORTH LN SW
Practice Address - Street 2:APT 6
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3324
Practice Address - Country:US
Practice Address - Phone:231-557-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-01
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008025224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant