Provider Demographics
NPI:1295841872
Name:JANDLE, DEBORAH LYNN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:LYNN
Last Name:JANDLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 MICHIGAN STREET NE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-862-3296
Mailing Address - Fax:616-466-7944
Practice Address - Street 1:1444 MICHIGAN ST NE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2028
Practice Address - Country:US
Practice Address - Phone:616-862-3296
Practice Address - Fax:616-466-7944
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010823381041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900030174OtherPRIORITY HEALTH MEDICAID
MIMI6092Medicare UPIN
MI900030174OtherPRIORITY HEALTH MEDICAID